Case Management Assistant - Case Management

The Case Management Assistant provides a broad range of support services to the Care Coordinators and Social Workers with their transition planning activities, including scheduling discharge appointments for primary care specialists or clinics, and clerical activities as needed. The Case Management Assistant collaborates with patients, their family, and members of the health care team to ensure a safe and effective transition through the continuum of care. Under the direction of the Care Coordinators or Social Worker and by order of the physician, the Case Management Assistant arranges post-acute care services when needed and documents all interactions with patients/families per departmental and regulatory standards. 

The Case Management Assistant provides utilization management support for the utilization review process. This role works collaboratively with all team members of Utilization Management, Patient and Provider Services, Claims Department, and other Care Coordination Department staff. In addition, the coordinator assists in identifying, tracking, and coordinating services for patients when needed. 

• Assists in locating facilities appropriate for patient’s needs: contacts skilled nursing facilities, Long Term Acute care and Acute Rehab Facilities to determine bed availability and communicates with the case management team.
• Assists patients with Durable Medical Equipment (DME) as needed to meet the home care needs of the patient as ordered by the physician and meeting payer requirements.
• Contacts insurance companies/ medical groups to acquire authorization for post-acute services when applicable. Obtains required signatures on Medicare IM prior to discharge. Verifies member eligibility before processing authorizations. Assists in verifying health plan benefits and coordinating ambulatory services
• Coordinates and facilitates discharge arrangements according to hospital policies and procedures, state and federal rules and regulations.
• Interfaces with physicians and outside reviewers to request appropriate orders and authorization for necessary post-acute services.
• Documents all discharge arrangements in the electronic medical record flow sheet under the appropriate care management navigator.
• Identifies the involvement of the patient/family/caregivers in the planning process and involves them in the formation of the plan of care and discharge needs. Works cooperatively and respectfully with patients/families and interdisciplinary teams in the completion of the discharge planning process. Functions as a patient advocate.
• Enters data and processes referral authorization requests, to include appropriate coding and quantities.
• Answers incoming calls from Providers, IPAs, Medical Groups and other internal and external calls and assists on the queues as needed.
• Monitors the Fax Inbox and appropriately distributes incoming faxes. Ensures that internal compliance security measures are met.
• Contacts facilities identified by the UM Nurses/Manager/Director/Medical Director to research any issues (i.e. contract, discharges, services provided). Identifies non-contracted providers and requests Letter-of-Agreements when requested.
• Requests support documentation from IPAs / Medical Groups as requested by the UM Nurses, Medical Directors, or Management
• Documents all patient specific information in appropriate information systems. Processes Extensions and Denial Letters, when needed.
• Prepares Utilization Review Reports as necessary. Provides assistance to the Claims Department, when requested.
• Assists the Case/Care Managers in coordinating and arranging services for members
   

Qualifications

Education

• High School Diploma/GED - required
• Assoc. Degree/College Diploma Business/Healthcare field - preferred

Experience

• 1 year Healthcare experience with a general knowledge of medical terminology. MUST complete a medical terminology course within 12 months of hire. Familiarity with community resources and social supports. - required
• 1 year Experience in an acute care hospital; skilled nursing facility, home health/hospice setting or medical office setting. - required
• 1 year Case Management/ Social Work support role - preferred
• 1 year Working in an acute care facility - preferred
• 1 year Previous utilization management or managed care experience; word processing spreadsheet skills also preferred. - preferred