Assoc Care Management Coord

Job ID: J126743
Company: Gateway Health Plan
Location: Home, DE, United States
Facility: Work From Home
Full/Part Time: Full time
Job Type: Regular
Posted at:

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Description

GENERAL OVERVIEW:  

This section contains a synopsis of the main purpose(s) or functions(s) of the job, indicating what is done.This information will be used to develop the position posting.

Perform accurate and timely processing of pre-certification requests for authorization of medically necessary health care services at the appropriate level of care, based on the benefits for the line of business, and in compliance with Gateway policies, procedures and regulatory requirements.

Document, process and route requests for services to the nurse reviewer and other departments based on documentation procedures, including review type, clinical information, and decision timeframes.

Follow policies and procedures to assure case completion and compliance with state and federal regulatory agencies.

Maintain or exceed department standards for call volume, response time and related production and quality measures.  May interact with other departments and providers to resolve cases.

ESSENTIAL RESPONSIBILITIES: 

This section lists the major duties and responsibilities of the position.This is not an exhaustive list of all job duties/functions/attributes.Depending on Role, essential responsibilities may also include oversight and management of people and functions described below.

1.Communicate effectively

  • Proactively inform designated individuals of the status of work assignment to assure decision timeframes and notification requirements are met
  • Communicate effectively with Utilization Management Staff, providers, other internal and external customers and management 

2.Route Cases Based on Established Guidelines

  • Provide accurate and timely routing of  service requests to the nurse reviewer to assure that the decision and notification timeframes are in compliance with regulatory guidelines
  • Process service requests meeting established guidelines, and document and route requests that are not permitted
  • Request additional information verbally and in writing when the information provided is not adequate to make a medical necessity determination

3.Maintain or exceed department call center standards

  • Adhere to line of business phone standards to assure regulatory requirements are met
  • Utilize phone functions to monitor the number of calls in queue and wait time
  • Utilize daily phone standard reports to assess opportunities for self improvement
  • Meet or exceed standards for other production and quality measures

4.Other duties as assigned or requested.

III. QUALIFICATIONS:

Education, Licenses/Certifications, and Experience (For Experience requirements please see appropriate role/level guide.  If not applicable, list experience requirements below.)

Minimum

Describe in objective and non-comparative terms the minimum education level, previous experience, specific knowledge skills and abilities the individual must have to perform the job.

Preferred

  • High School Diploma / GED
  • Experience in customer service
  • Experience in typing, keyboard and computer skills
  • Work experience in medical terminology
  • Associates degree or certification in a health related occupation
  • Work experience with ICD-9 and/or CPT coding

Knowledge, Skills and Abilities  (This section describes additional preferred characteristics)

Compliance with all regulatory agency requirements is essential as consequences could result in potential for sanctions up to possible contract termination for all product lines

IV. SCOPE OF RESPONSIBILITY  (People Management Responsibility)

Does this role supervise/manage other employees?          No  □     Yes   □         

If yes, indicate the number of direct reports: 

V. WORK ENVIRONMENT

Most company positions are performed in a normal office environment.   Please use this section to describe unusual work conditions, such as exposure to high noise levels, temperature extremes, etc.  If “none, “please indicate with “Not Applicable.”

Is Travel Required?

No   □

Yes   □          

Unusual Working  Conditions

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This job requires the ability to work as a team member.  Additionally, this job requires the willingness and ability to report to work on a regular and timely basis and may require irregular work hours, holidays and/or wee

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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