Case Management Lead

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Day - 08 Hour (United States of America)

This is a Stanford Health Care Tri-Valley job.

A Brief Overview
The CM Liaison Lead serves as a liaison between SHC-VC UM/CM team and Health plans. Will serve as a resource to the UM/CM team members and is responsible for processing authorizations within the scope of their assignment and will oversee the CM Liaison Team in the daily operations.

Locations
Stanford Health Care Tri-Valley

What you will do

• Utilize knowledge and experience to analyze contractual or administrative issues related to the requests.
• Identify additional information needed and ability to research and understand benefits and criteria.
• Accurately identify when and how to refer cases to appropriate clinical personnel or take other actions as necessary or required.
• Coordinate with other insurance coordinators and the medical review staff.
• Forwards all request that require additional clinical review to determine medical necessity criteria to the pre-authorization nurse for determination.
• Work independently and in collaboration with the clinical UM team members with timely completion of the UM/CM WQ for ADT, Rooming, Medical necessity, and Quality assurance.
• Assist with the clinical UM team to validate the physician orders and ensures admission is coded correctly.
• Manages denial appeals. Prepares, assists the clinical UM team for review, submits within deadlines and follows up on outcome.
• Develops and maintains the system to oversee all prior authorization and ensures that clinical information is completed timely and accurately.
• Stays in contact with CM/UM department to ensure clinical interventions are handled properly.
• Oversee the CM Liaison Team in the daily operations.
• Assist with the API and Staffing schedule.
• Responsible for ordering medical, non-medical supplies and transportation vouchers for the department.
• Contributes to the efficiency of the department by being flexible and cross-trained on other functions.
• Works on a variety of special projects and assumes other duties as assigned by the UM Director and CM Team leaders.
• Employee must perform all duties and responsibilities in accordance with the C-I-CARE Standards of the Hospital. C-I-CARE is the foundation of Stanford Healthcare – Tri-Valley’s patient-experience and represents a framework for patient-centered interactions

Education Qualifications

• High School Diploma or GED Required
• Associate's Degree
• Bachelor's Degree degree in Health or Business Administration Preferred

Experience Qualifications

• 2+ years to 3 years experience and training in the Hospital Utilization Management, Health care and/or Managed care field. Required

Required Knowledge, Skills and Abilities

• Ability to make sound judgement
• Excellent communication and interpersonal skills
• Ability to work independently and function effectively as a member of an interdisciplinary team.
• Basic Computer skills required.
• Strong advocacy and problem-solving skills
• Strong attention to detail
• Knowledge of acute care in relation to safety, security and joint commission standards

Licenses and Certifications

• Current American Heart Association Certification for Basic Life Support for Healthcare
  Providers required .

These principles apply to ALL employees:

SHC Commitment to Providing an Exceptional Patient & Family Experience


Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery.



You will do this by executing against our three experience pillars, from the patient and family’s perspective:

• Know Me: Anticipate my needs and status to deliver effective care
• Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health
• Coordinate for Me: Own the complexity of my care through coordination

Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.

Base Pay Scale: Generally starting at $31.94 - $41.20 per hour

The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.