Health Care Coordinator 2

State of Nevada•Reno, NV

3d•Onsite

About The Position

This position is located within the Nevada Health Authority in Reno, Nevada, and is responsible for assessing Medicaid members' eligibility and service needs across multiple Medicaid programs, including Care Coordination and the Katie Beckett Option. The incumbent coordinates access to medically necessary services, conducts home, community, and provider visits, monitors compliance with state and federal requirements, maintains accurate case documentation, and collaborates with recipients, families, providers, and community partners to support the health, safety, and well-being of Medicaid recipients. This position requires current licensure with the Nevada State Board of Nursing or Social Work and may include driving up to 50% of the workday. Health Care Coordinators perform professional work related to program operations and auditing providers to ensure compliance with program policies and regulations. They evaluate individuals referred to the medical services program and provide ongoing case management services to Medicaid eligible clients; evaluate the need for medical services, treatment, equipment and supplies and authorize payment; screen individuals to determine appropriate level of care in nursing homes; review programs to ensure services are being provided in a cost effective manner; participate in program development by providing input on policies and procedures, forms, medical coverage and system enhancements.

Requirements

Licensure as a Social Worker or professional licensure or certification in a medical specialty applicable to the assignment, and one year of of professional experience providing case management services in a social or health related field.
One year of experience as a Health Care Coordinator I in Nevada State service.
Licensure and an equivalent combination of education and experience.
Working knowledge of: theories, principles, practices and methods of social work, nursing, or a health care profession applicable to the program assignment; case management practices applicable to the program assignment; interviewing techniques; crisis intervention techniques; assessment tools used to evaluate clients; normal and abnormal human growth, behavior and development.
General knowledge of: federal regulations and State laws applicable to the program assignment; anatomy, physiology, pharmacology, and psychology; medical and pharmaceutical terminology; services, roles and responsibilities of social service agencies; impact of diseases and disabilities on individuals.
Ability to manage a caseload of individuals with significant physiological, developmental, emotional and psychological problems and related disorders.
Ability to determine initial and ongoing ability to meet the criteria for pertinent agency programs.
Ability to read and interpret program regulations and policies.
Ability to access and verify information using computer equipment and records.
Ability to analyze health and social information to determine risk factors, client needs and functional level.
Ability to monitor and evaluate services provided.
Ability to research, review, and interpret medical records and make recommendations.
Ability to develop and implement plans of care including authorizing services as appropriate.
Ability to document case activities and write reports.
Ability to provide instruction and direction to clients and others in group or individual settings.

Responsibilities

Assess potential client needs for case management services using assessment tools to identify social service and/or medical needs.
Develop and implement plans of care for those determined to be eligible for services.
Counsel and refer clients to services and/or contract with providers for services.
Maintain contact with clients through home visits and telephone calls.
Monitor the quality and cost of services provided to clients.
Periodically update plans of care.
Submit payment authorization requests.
Maintain case files.
Participate in periodic reviews of facilities providing care to Medicaid eligible clients to validate and ensure adequacy of services and resident care.
Ensure reimbursement matches the cost of services provided.
Monitor nursing facility quality indicator reports.
Screen and assess Medicaid clients regarding discharge to community-based care.
Review medical records.
Document findings and deficiencies on appropriate forms.
Prepare reports of findings and participate in exit conferences.
Participate in independent professional reviews of providers to determine the quality of care, compliance with patient rights, and appropriateness of placement as assigned.
Review health care providers and fiscal agents to ensure clients are receiving appropriate services and payment is correct for services received.
Ensure providers and fiscal agents are in compliance with division policies and procedures.
Ensure employee health, certification and training needs are appropriate and properly documented in personnel records.
Verify client records have appropriate documentation and that authorized services correlate with services provided.
Confirm termination of services were appropriately documented and mandated reporting requirements were met.
Provide technical assistance regarding policies and procedures.
Complete written documentation using appropriate format.
Identify areas needing improvement and review plans of correction.
Process payment authorization requests from providers to ensure the requested service, treatment, equipment or supplies are medically necessary and in compliance with Medicaid criteria prior to approving or denying requests.
Review pertinent medical information and previous requests.
Evaluate medical necessity to justify payment by comparing the diagnosis and other medical information with the request.
Refer requests to a medical consultant for another medical opinion as necessary.
Render determinations in accordance with Medicaid policy and notify providers of decisions.
Review records from the fiscal agent, providers, clients and computer generated reports in order to identify abuse and potential fraud and to ensure claims were paid properly by the fiscal agent.
Refer financial errors to the fiscal agent for adjustment of charges and refer potential cases of fraud and abuse for further investigation.
Explain proper billing procedures to contract providers selected by the client.
Monitor the quality of care given by the provider to clients.
Submit billings for services provided to the fiscal agent for payment.
Perform related duties as assigned.
Under direction, incumbents perform the full range of duties described in the series concept.
In addition, incumbents at this level may intermittently serve as the project lead of a case management team, function as coordinator of a specifically assigned portion of a program, and assist in training other Health Care Coordinators and providers.