Under the supervision of the Director of Case Management (DCM) or designee, this role completes various duties to enhance the efficiency of the Case Management Department, as well as support the daily functions of the case managers. This role assists in securing arrangements for the discharge transition and post-acute services. While monitoring the revenue cycle process related to insurance certifications, insurance verification, peer-to-peer completion, and denial/appeal tracking, this position serves as a liaison between the Case Management Department, payers, and additional entities.
A. Essential Functions:
Provides assistance to the case management staff, including but not limited to, creating and faxing referral packets, organizing admission and discharge patient records, making phone calls, obtaining signatures, or any other assistance needed determined by the DCM
Assists the case management team in scheduling family conferences.
Assists the case management team by making necessary arrangement for post-discharge follow up care.
Functions as the point of contact and liaison for the hospital Case Management Department staff regarding clinical insurance review completion and/or issues.
Forwards the necessary patient clinical information for all admission, concurrent, and retrospective insurance reviews to payers for the completion of medical necessity reviews.
Monitors, documents, and tracks payer responses/requests of completed clinical reviews, including approvals, appeals, and denials, and communicates these to the appropriate personnel [hospital staff, physician, DCM, Claims Management, and Centralized Business Office (CBO)].
Monitors and tracks the total hospital certified days of the patient for payers (commercial, managed care, and Medicaid) and communicates missing certifications to the DCM and CBO.
Initiates and completes insurance pre-certification for patients lacking certification, due to pre-admission issues, concurrent insurance changes, or outgoing hospital planned procedures. Communicates pre-authorization outcomes to appropriate personnel (hospital and CBO).
Organizes and prepares the necessary clerical elements for the weekly Interdisciplinary Team Meeting to function timely and efficiently.
Performs general daily operational tasks/clerical support (i.e. phone calls, emails, faxes, copies, etc.) for the Case Management Department and as determined by the Director of Case Management (DCM).
.Performs additional duties to assist the Case Management Department staff, support the revenue cycle, and subsidize the discharge planning processes as necessary and assigned.
B: Company Specific
Adheres to dress code, appearance is neat and clean and wears appropriate identification while on duty.
Completes annual health, safety, and education requirements. Maintains professional growth and development.
Maintains confidentiality of all patient and/or employee information to assure patient and/or employee rights are protected.
Demonstrates knowledge of the principles of growth and development over the life span and the skills necessary to provide age appropriate care to the patient population served.
Reports to work on time as scheduled; adheres to policies regarding notification of absence.
Attends all mandatory in-services and staff meetings.
Represents the organization in a positive and professional manner.
Complies with all organizational policies regarding ethical business practices.
Communicates the mission, ethics, and goals of the hospital, as well as the focus statement of the department.
Maintains current licensure/certification for position, if applicable.
Consistently demonstrates Guest Relation's skills to patients, physicians, visitors, employees, and any other individuals with whom they may come in contact.
Consistently follows departmental and hospital Health, Safety, Security, Hazardous Materials policies and procedures.
Service Excellence Elements
Pride – (Owning and feeling proud of work quality and our mission.)
Performs work that reflects ownership and is a credit to self and positively represents Kindred.
Teamwork – (Achieving greater results through cooperation and recognizing contributions.)
Cooperates with co-workers while performing duties leading to everyone being able to achieve success and giving recognition where it is due.
Compassion – (Listening and focusing on the patient/resident; taking sincere, appropriate actions.)
Meets the patients' needs and concerns by consistently acting in a patient-focused manner.
Integrity – (Doing the right thing.)
Demonstrates adherence to a strict moral or ethical code in performance of duties by always seeking to do the right thing.
Respect – (Treating others as they would like to be treated; valuing others.)
Acknowledges the worth of others through professional greetings, proper telephone etiquette, patience, and common courtesy.
Fun – (Enjoying work and being an enthusiastic participant.)
Demonstrates a positive attitude toward work and devotion to the task at hand.
Professionalism – (Assuring skills (licensures) are current; looking and acting the part while performing at the highest level.)
Keeps skills, competencies and required licensures/certifications current; displays mastery over attitude and behavior and pride in appearance. Consistently performs duties to the best of abilities.
Responsibility – (Being accountable, doing what is expected or beyond; assuring what needs to get done, gets done.)
Takes ownership of all aspects of duties shown through reliable, timely performance and accountability.
Education : College degree preferred in healthcare related field
Licenses/Certification: LPN or social work degree/license preferred
Experience: 1-3 years hospital or post-acute healthcare experience with preference in case management or clinical department. Proficient with WORD and EXCEL software, keyboard typing, and general office equipment .
Working knowledge of insurance certification process, insurance verification, ICD-10 coding, electronic medical record, and Meditech system.
Clinical knowledge to read, interpret, and communicate information in the medical record that identifies diagnoses, treatment plans, interventions, and medical necessity for hospitalization.
Ability to maintain confidentiality of all patient and/or employee information to assure patient and/or employee rights are protected.
Ability to interface on all levels of the organization by demonstrating excellent interpersonal skills.
Ability to communicate effectively, both in writing and verbally.
Ability to work cooperatively and collaboratively as a member of a team.
Ability to work under stress and to respond quickly in emergency situations.