"Case Management Coordinator - Inpatient Specialty Program"

Job Description

The Case Management Coordinator provides support to the utilization review process. The coordinator 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. The position requires good written and communication skills and the ability to interact with Medical Directors, Providers, CSMNS members, Medical Group and IPA's to ensure the delivery of high quality, cost-effective healthcare and aligned with all state and federal regulations and guidelines.

Duties and Responsibilities:

• 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.
• Is responsible for the Fax Inbox and appropriately distributes incoming faxes. Ensures that internal compliance security measures are met.
• Verifies member eligibility before processing authorizations.
• 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.
• Processes Extensions and Denial Letters, when needed.
• Prepares Utilization Review Reports as needed.
• Assists the Case/Care Managers in coordinating and arranging services for members.
• Provides assistance to the Claims Department, when requested.
• Documents all patient specific information in appropriate information systems.
• Assists in verifying health plan benefits and coordinating ambulatory services.
• Acts as a liaison, captures information and documents all patients referred to the ACM/disease state management programs.
• Reviews hospital admissions information and enter/update inpatient, SNF, home health and DME referrals as needed.
• Prints and distributes daily census.
• Seeks and accepts referrals for target patient populations, i.e. fragile seniors, catastrophic and transplant cases, frequent utilizer of ER and inpatient services, and patients diagnosed with specific diseases (cancer, asthma, COPD, AIDS, etc.).
• Assists in coordinating care for specific high risk/high cost patient population, including referrals to community resources, facilitation of medical services, referral to ancillary providers, etc.

Qualifications

Education:

High school diploma/GED required.

Experience:

One (1) year of healthcare experience, a general knowledge of medical terminology and experience with community resources and social supports required. One (1) year of utilization management or managed care experience preferred.

About Us

Cedars-Sinai is a leader in providing high-quality healthcare encompassing primary care, specialized medicine and research. Since 1902, Cedars-Sinai has evolved to meet the needs of one of the most diverse regions in the nation, setting standards in quality and innovative patient care, research, teaching and community service. Today, Cedars-Sinai is known for its national leadership in transforming healthcare for the benefit of patients. Cedars-Sinai impacts the future of healthcare by developing new approaches to treatment and educating tomorrow's health professionals. Additionally, Cedars-Sinai demonstrates a commitment to the community through programs that improve the health of its most vulnerable residents.

About the Team

With a growing number of primary urgent and specialty care locations across Southern California, Cedars-Sinai?s medical network serves people near where they live. Delivering coordinated, compassionate healthcare you can join our network of clinicians and physicians to improve the healthcare people throughout Los Angeles and beyond.