Care Management Coordinator

Company Name:
Catholic Health Initiatives
Care Management Coordinator-1400010021
The primary role of the Care Management Coordinator is to coordinate the referral and prior authorization processes in accordance with the benefit contract guidelines and criteria. Supports resolving provider reconsiderations and associated education. Leads required training for staff, delegates, and providers. Builds provider relationships across the network to support Soundpath Health's Utilization Management expectations and guidelines. Using good oral and written communication skills, implements, maintains and executes procedures and processes by which Soundpath Health performs its referrals and prior authorizations. Works closely with the Care Management team to assure members are managed across the continuum of care.
_Essential Duties and Responsibilities_
Support Care Management Coordinator functions to ensure compliance with company procedures and policies.
Acts as Subject Matter Expert (SME) for all care management coordinators.
Provides training and guidance for care management coordinators annually and/or as needed.
Directly responsible for coaching and development of department team and delegates.
Supports the Grievances & Appeals process.
Responsible for documenting and maintaining desk procedures used by Care Management Coordinators.
Process phone and fax authorization requests for medical services from physicians and hospitals (providers) in an efficient, accurate, and customer focused manner in accordance with established criteria sets and established Soundpath Health benefits and requirements.
Verify eligibility and benefits for services requested by Primary Care and Specialty Physicians from Health Plan guidelines and maintains documentation in system.
Proficiently logs all telephone inquiries from providers and members regarding problems, benefits inquiries, referral and authorization status or copies of letters and data
Determine when to refer to Care Management Manager for higher level of review when indicated by request
Maintain tracking and monitoring of assigned referrals at all levels of review for instant retrieval
Perform daily computer entry of referral information following established protocols and guidelines for monitoring quality and timeliness of entry with minimal errors
Provides accurate and timely daily Activity Reports as required in Department Policies for production information
Meet production standards for performance as set by supervisor for the department
Coordinate and maintain a system for receiving, processing, and resolving provider reconsiderations in accordance with all applicable contract provisions, plan policies, procedures, rules and regulations and coordinate with Claims and other departments to ensure timely resolution
Build, develop, and administer New Hire systems training for all new Care Management staff and provide systems, benefits and other required training to delegates and providers
Develop a provider and delegate training pertaining to relevant standards and requirements regarding Utilization Review protocols, policies and procedures to reduce physician dissatisfaction and provide more useful information to facilitate timely patient care
Respond to daily questions from delegates, medical offices, hospitals, skilled nursing facilities, and home health agencies about the necessary steps of the medical referral and authorization process, benefit interpretations, and claims processing
Develop educational materials geared to enhance understanding and knowledge of benefits, standards, and processes within Soundpath Health
Initiates communication with delegated groups, physicians, their office staff, and outside providers as needed to gather information for processing referrals and authorizing services to Managed Care patients
Support Concurrent Review and Case Management as needed
Assist in the development and implementation of job specific policy and procedures pertaining to but not limited to accurate data entry, rapid telephone response, provider reconsiderations, and following guidelines for authorizations
Review current and proposed Federal, State, CMS, and NCQA standards that regulate Utilization Management activity
Assist with and conduct review of retrospective referrals and/or claims to verify all authorized services were performed as specified
Assist in preparing and submitting projects, reports, or assignments as needed to meet department initiatives and/or objectives
Other duties as assigned
_Education and Experience_
High School education required
Associate's or Bachelor's degree in medical or health care management and/or nursing degree preferred
2 - 4 years demonstrated working knowledge of Managed Care products, including Senior Commercial and Medical Plans
2 - 4 years demonstrated working knowledge of Federal and State regulatory agencies (i.e. CMS, NCQA, HCFA, DOC)
2 - 4 years demonstrated working experience with prepaid health care delivery systems, such as HMOs
Experience in lieu of above qualifications will be considered.
_Certificates, Licenses and Registrations_
LPN preferred, non-clinical with experience in managed care will be considered
_Additional Responsibilities_
Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor at all times
Adheres to and exhibits our core values:
Reverence : Having a profound spirit of awe and respect for all creation, shaping relationships to self, to one another and to God and acknowledging that we hold in trust all that has been given to us.
Integrity : Moral wholeness, soundness, uprightness, honesty and sincerity as a basis of trustworthiness.
Compassion : Feeling with others, being one with others in their sorrows and joys, rooted in the sense of solidarity as members of the human community.
Excellence : Outstanding achievement, merit, virtue; continually surpassing standards to achieve/maintain quality.
Maintains confidentiality and protects sensitive data at all times
Adheres to organizational and department specific safety standards and guidelines
Works collaboratively and supports efforts of team members
Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff and the broader health care community
Catholic Health Initiatives and its organizations are Equal Opportunity Employers. CB
Job: Administrative and Clerical
Primary Location: WA-Federal Way-Soundpath Health
Shift: Day
Scheduled Hours per 2-week Pay Period: 80
Weekends Required: None
Status: Full Time
Req ID: 1400010021

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