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Department: Case Mgmt/Social Services
Status: Full Time
Shift: Days
Hours Per Shift: 8 Hour Shift
Job Details:
    • Job Objective: A brief overview of the position.
      • Position works under the supervision of the Director, Case Management Department. Is responsible for providing utilization management secretarial support to CM Department. Processes all requests for concurrent and retrospective reviews. Responds to inquiries from Patient Financial Services regarding updates on authorization status and denials. Prepares Medi-Cal TARs along with required paperwork for onsite Medi-Cal Reviewer. Retrieves medical records for retro-reviews and appeals. Performs clerical reception and general office duties involving typing, record and file maintenance, faxing, computerized information retrieval and telephone communication.
    • Reports to
      • Director, Case Management
    • Supervises
      • N/A
    • Ages of Patients
      • N/A
    • Blood Borne Pathogens
      • Minimal/ No Potential
    • Qualifications
      • Education
        • Preferred: Medical terminology
      • Licensure/Certification
        • N/A
      • Experience
        • Required: One (1) year recent general office/secretarial experience.
        • Preferred: Prior experience with payor authorization processes.
    • Essential Responsibilities
      • Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
      • Faxes reviews, logs review requests, refers telephonic review requests to appropriate Service Line Case Manager.
      • Receives and communicates information regarding insurance and admit date changes from Financial Counselors to Case Managers.
      • Tracks insurance reviews and obtains medical records for retro-review process.
      • Educates staff on processes for communicating review needs and related requests.
      • Notifies UM Specialist of payor denials and assists with denial/appeal process as directed; attends Denial Committee meetings.
      • Reviews daily admissions and discharges to determine reviews/authorizations requiring processing, including requesting and obtaining medical records for retrospective reviews.
      • Tracks, documents and faxes utilization reviews to appropriate insurance/review agencies.
      • Calls insurance agencies for final inpatient authorization verification; enters information into Midas and notifies Business Office staff of problematic inpatient authorizations..
      • Organizes, copies and distributes morning reports.
      • Performs duties related to the Medi-Cal TAR process: Looks up new Medi-Cal admissions and discharges daily, initiates TARS, logs new TARs on check list, distributes TARS to Service Line Case Managers; initiates retro-TARs as requested by Business Office.
      • Retrieves and communicates voice mail messages from review agencies.
      • Determines workload priorities and is able to complete a typical day’s assigned workload within the scheduled shift.
      • Assures maintenance of department equipment and educates staff on equipment usage.
      • Assists all members of the department by retrieving information from files and computer, making photocopies, mailing projects, and running errands
      • Takes on additional duties during periods of heavy workload. and/or when covering for co-workers’ vacation or unexpected absence.
      • Types correspondence, reports, forms and other documents as requested.
      • Answer telephone promptly and courteously within three (3) rings.
      • Performs special projects and other duties as directed.

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