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On-Call Required:

Hourly Pay Range (Minimum - Midpoint - Maximum):

The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant's years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

This position requires working 2 weekends per month minimum, will float to all SCMG facilities based on the business need and will require working at least 1 major and minor holiday.

What You Will Do
To review more complex requests for medical care and services, if part of the discharge plan, inpatient admission, skilled nursing facility admission including requests for outpatient care, retrospective claim review, medical equipment, medication issues and acquisition, home health in accordance with Sharp Community Medical Group (SCMG) referral guidelines. To provide, support, and help facilitate care coordination services provided by the Case Manager. This position is responsible for the care and services delivered to a specific SCMG region and/or specific hospital.

Required Qualifications

• 3 Years Working in the health care field, preferably HMO or delegated risk medical group/IPA setting.

Preferred Qualifications

• Other : Successful completion of Medical Terminology class, ICD-10 and CPT coding classes (or equivalent work experience).
• Other : Successful completion of Medical Assistant Program or equivalent.
• 1 Year Relevant experience in referral processing, discharge coordination, data entry, knowledge of medical terminology, eligibility, and benefit coverage preferably in a managed care environment.

Essential Functions

• Department Support
  Prepares the inpatient census. Confirms report accuracy, makes modification as warranted to reflect accurate and current information. Verifies current insurance plan eligibility. Reports statistics to the manager of Inpatient Care Management. Reports re-admission within 30 days of previous discharge. Reports patient's enrolled in a Sharp Case Management program to HCM.
  Confirms patients reported in Emergency Room. Informs HCM's and MD's.
  Reviews face sheets and H&P for age, diagnosis and potential discharge needs.
  Review patient list and prioritize/plan for the day.
  Coordinates timely specialty consultations for SCMG inpatients. Confirm procedures are made on the appropriate schedules, i.e. surgery, radiology, etc.
  Manages correspondence to members and PCP, health plans and other service providers.
  Generates phone calls to members, physician offices, health plans, and providers to assist in care coordination under the guidance of case managers. Including reviewing patient's needs and condition with Skilled Nursing Facilities for placement.
  Organizes and maintains case files.
  Provides clerical support and assistance to the Case Management team. Contributes to the continuous improvement initiatives of the Case Management team to deliver quality interventions in a timely manner.
  Delivers IMM letter to inpatients in accordance with hospital policies and procedures.
  Assist the HCM by relaying information regarding patient demographics and the distribution of lists of contracted facilities for Skilled Nursing.
  Contacts hospital admissions regarding patient bed type status changes (ie inpatient to observation).
  Knowledgeable in Microsoft Office applications and additional applications directly related to the Inpatient Unit.
  Document quality issues and forward to SCMG Quality Management department.
• Discharge and Patient Follow Up
  Review with Case Managers patients and their discharge needs.
  Confirm discharges from the previous day and ensures discharge paperwork is forwarded to the appropriate department.
  Prepares discharge paperwork for planned discharges.
  Facilitates post discharge calls to those patients discharged the day before or over the weekend; to ensure the patient has received: DME, medication, home health visits, follow up appointments and assist patients with issues arising from the categories listed above.
  Coordinates timely specialty consultations for SCMG inpatients. Confirm procedures are made on the appropriate schedules, i.e. surgery, radiology, etc.
  Generates phone calls to members, physician offices, health plans, and providers to assist in care coordination under the guidance of case managers. Including reviewing patient's needs and condition with Skilled Nursing Facilities for placement.
  Sets up the appropriate transportation through contracted ambulance service when needed.
  Facilitates setup, delivery and/or implementation of the following: Skilled Nursing Facility, durable medical equipment, scheduled follow-up procedures and medication delivery.
  Updates EHR or stand alone database with patient discharge information regarding consultations, and patient follow up calls.
  Facilitates the distribution of patient information to the Skilled Nursing Team to include the following: patient's skilled need, patient's living situation, patient's chart notes (progress notes, physician orders, H&P, and patient's need for transportation (dialysis, appointments etc.)
• Industry Skills and Competency
  Obtain detailed benefit coverage for the more complex requests for service specific to member plan coverage.
  Apply the principles of SCMG guidelines and Health Plan benefit guidelines to approve referrals designated at the CRC level.
  Investigate and follow-up on all eligibility issues in accordance with health plan and SCMG guidelines.
• Process Referrals for Prior Authorization
  Coordinate, review and process the more complex referrals for prior authorization for medical care and services, including emergency room, inpatient admission, durable medical equipment, home care and other miscellaneous services for the efficient and effective delivery of inpatient services.
  Performs review of all prior authorization referrals. (Responsible for all levels of the referral from generation, approval and acquisition).
  Obtains necessary medical information for use by themselves, Medical Directors, the Hospitalist Physician and/or Case Manager.
  Identifies and refer requests for review by higher level staff (Medical Director, Hospitalist or HCM) within department turn around time (TAT) standards.
  Researches and assist in the denial process - gathers documentation after review by medical director, ensure packet information is complete, assesses and select the appropriate denial reason. Maintain mandated TAT for denials.
  Obtains and gathers clinical information from multiple sources including use of Sharp and/or Hospital applications to retrieve patient medical records for review by Hospitalist Case Managers, SNF's or outpatient service providers.
  Verifies and documents eligibility and benefit details.
  Obtains prior authorizations for specific medications, through SCMG Pharmacy or through the patient's health plan when applicable. Has all information available to help with the review process.
  Informs and distributes health plan criteria to the Medical Director, CM or themselves to make a determination regarding an authorization for service or equipment.
  Updates inpatient IDX referrals with correct diagnoses, bed type and disposition.
  Generates or assist in the dissemination of Case Management Referrals.
  Generate informational referrals for patients that are accepted to hospice while admitted as inpatient.
  Research and interpret all ICD-10, CPT and HCPC coding using appropriate tools.
  Make determination on the more complex claims that are designated CC authorization level within SCMG TAT guidelines.
  Coordinates, reviews and processes more complex retrospective claims for medical care and services, including, SNF inpatient admission, medical transportation, durable medical equipment and other miscellaneous services for the efficient and effective facilitation of claim adjudication.
  Tracks and informs identified personnel of expired patients.
• Professional Development
  Actively identifies gaps in skills and competencies and participates in seminars/classes to enhance gaps.
  Attends and actively participates in department/team process/quality improvement activities.
• Scheduling
  EMPLOYEE IS REQUIRED TO:
  Work 2 weekends per month minimum
  Float to all SCMG facilities based on the business need.
  Work at least 1 major and minor holiday.

Knowledge, Skills, and Abilities

• Excellent organizational, managerial and time management skills, with the ability to multitask.
• Excellent analytical, problem solving, and supervisory skills.
• Proficient in medical terminology, referral management, current standards of clinical practice, and mentorship
• Proficient in use of ICD-10, CPT4 and HCPC coding systems.
• Proficient in typing and computer data entry (45 wpm).
• Excellent verbal and written communication skills.
• Ability to read, speak and hear English clearly.
• Ability to work independently in research and decision making with minimal direction from higher levels of staff.
• Float between Sharp HealthCare facilities; must provide own transportation.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class