Job Summary:The Post Acute Care Specialist -Integrated Care is responsible for coordinating level of care transition and post-acute UM activities to ensure compliance with timely processing of authorization, level of care, and disenrollment requests. The Specialist processes requests into clinical systems for review, contacts the provider, member, or other stakeholder if additional and/or clinical information is required, and communicates with stakeholders to complete disenrollment functions and support members to maintain program eligibility.
Essential Functions:- Convert information obtained from providers, members, care coordinators/care managers, waiver service coordinators, or other stakeholders (received via fax, phone, provider portal or mail) into electronic records while verifying member eligibility, provider network status, and benefit coverage; communicate information to appropriate team members via established processes within the clinical documentation system or other communication methods.
- Review requests and communicate changes in eligibility , duplicate requests, and items not covered by medical benefit to providers or other stakeholders.
- Initiate process for routing prior authorizations or level of care reviews requiring medical necessity review by clinical staff.
- Communicate with providers, care coordinators/care managers, waiver service coordinators, or other stakeholders regarding prior authorization, level of care, or disenrollment requests and outcomes; provide support to providers as appropriate.
- Provide authorization, level of care, or disenrollment information to provider, facility, member, care coordinator/care manager, waiver service coordinator and/or other stakeholders per established processes or upon request.
- Assist Clinical team as directed to ensure requests for authorization or level of care that require clinical review are received and processed timely.
- Assist clinical teams and leaders in gathering data for reporting.
- Assist in processing disenrollment requests in required systems and document actions in clinical documentation system.
- Maintain awareness of current workload aging and respond with appropriate sense of urgency.
- Expectation to meet department standards and goals.
- Collaborate across company departments to assist with issues and questions.
- Maintain knowledge and understanding of all processes and procedures for multiple markets.
- Sufficiently cross-trained in multiple markets and products.
- Adhere to all departmental and company policies and procedures.
- Perform any other job related duties as requested.
Education and Experience:- High School or GED required
- Minimum of eighteen (18) months of clinical and/or insurance experience, ore related healthcare education or certification (i.e. STNA, MA, etc.) required
- Managed care experience preferred
- Experience with post-acute, nursing facility and/or HCBS waiver services preferred
Competencies, Knowledge and Skills:- Computer proficiency with knowledge and experience with Microsoft Office in a Windows based environment
- Ability to analyze information
- Communication skills
- Ability to work independently and within a team environment
- Attention to detail
- Proper grammar usage
- Critical listening and thinking skills
- Professional phone etiquette
- Customer service oriented
- Decision making/problem solving
- Change resiliency
- Knowledge of behavioral health systems
- Ability to accurately communicate summary information in a written format
Licensure and Certification:- Medical Terminology Certificate preferred
Working Conditions:- General office environment; may be required to sit or stand for extended periods of time
- Position required the flexibility to work evenings, weekends and/or holidays, as needed
- Travel is not typically required
Compensation Range:
$41,200.00 - $66,000.00
CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Hourly
Organization Level Competencies
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
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Brand=CareSource
