Summary Description

Under general supervision and according to established policies and procedures, provides assistance to Care Management functions for the site. Participates as a member of the Care Management Team to facilitate process flow in care coordination activities and transition planning. Communicates with Third Party payers and other community resources to assist in the patient disposition process. Interfaces with Patient Financial Services on issues related to eligibility, benefit coverage, and appropriate provider. Performs input into various databases as appropriate for utilization management, LOS management and Denial Management activities. Audits data input and corrects errors, as needed. Investigates and responds to inquiries related to the authorization process, benefit coverage and general concerns regarding policies and procedures. Maintains necessary utilization review files for all patients in the hospital. Validates discharge dispositions and assists with issuing Medicare Important Message letters prior to discharge. Establishes and maintains effective relationships with physicians and all other staff members, internally and externally. Identifies problems or any dissatisfaction experienced by any customer or referring source and works to resolve them to a high degree of service excellence. Uses positive interpersonal skills to effectively resolve conflict. Promotes a positive customer relations environment. Performs related clerical/secretarial duties as needed.

Minimum Qualifications

1. High school diploma or equivalent.

2. One to two years related experience in an outpatient clinic or hospital setting, including six to twelve months of data entry experience.

3. One to two years work experience in an insurance, medical records, billing or related area desirable.

4. Medical Assistant certification, license to practice as a Licensed Practical Nurse (LPN), or college coursework in heath care preferred.

5. Additional training in computer applications preferred.

6. Working knowledge of medical terminology desired.

Skills Required

1. Interpersonal skills to effectively communicate with third party payers, hospital staff and various other internal/external contacts, and to answer telephone inquiries.

2. Written and oral communication skills.

3. Knowledge of managed care and referral processes.

4. Manual dexterity to type and enter data using the computer.

5. Ability to utilize computer systems; computer skills and knowledge of various software packages

6. Ability to push, pull and/or lift objects weighing up to 20 lbs.

7. Ability to understand and apply various third party payer requirements, verification procedures and benefits.

8. Ability to work within a complex environment and handle multiple priorities.

Mathematical ability to perform basic calculations such as percentages, addition, multiplication, etc