Career Opportunities at Acacia

 

Job Details


Casa Promesa


Managed Care Coordinator  Bronx, NY  : 6/8/2023
Job Description

Job ID#:

3563

Job Category:

Casa Promesa

Position Type:

Full Time


Details:

POSITION OVERVIEW:                                                                                                                        
 
The Managed Care Coordinator is responsible for the day-to-day functions of collaborative communication with
external case managers at referring provider facilities and/or managed care organizations (MCO) for data
collection, interpretation, and certification/recertification from third party payers at pre-admission through
discharge, ongoing medical necessity reviews and interdisciplinary team support with respect to MCO
requisites.  In addition, this position is responsible for having a thorough understanding of patient treatment
plans through participative discussions with the care plan (interdisciplinary) team, identifying and referring
requests for services to the Medical Director when guidelines are not met and reviewing inpatient and outpatient
services requiring MCO approval. Salary is: $53,000 per year

KEY ESSENTIAL FUNCTIONS:                                                                                                            
 
  • Obtain required pre-authorization/certification of specified services from MCOs and communicating end of benefit status and/or reimbursement changes to Finance and others as deemed necessary.
  • Conducting ongoing medical necessity reviews, which may be pre-service, concurrent and/or retrospective in nature, by evaluating clinical data and submitting appropriate documentation to update the patient/resident's status to the MCO as scheduled.
  • Referring MCO denials and non-covered medical services to the Medical Director for appeal determination.
  • Conduct medical record reviews of all managed care patients within the first 24 to 72 hours (if admitted on a Friday after 5:00pm) then weekly as required to promote desired clinical and financial outcomes by, but not limited to:
    1. Meeting with all managed care residents/patients to better assist in the selection of appropriate provider resources and identification of quality and cost-effective services throughout the continuum of care.
    2. Validating appropriateness of services rendered and attending medical rounds as needed and where requested.
    3. Acting as a resource to the interdisciplinary team regarding MCO requirements for admission, continued stay and discharge planning.
    4. Providing early identification of covered care and ensuring that claims are approved when the requirements are met.
  • Collaborate with Medicine, Nursing and Rehabilitation to identify discharge needs and coordinate with Social Services in the creation and implementation of a discharge/transfer plan.
  • Coordinates post-discharge follow-up care with selected patients and community providers.
  • Maintain skills to perform multiple functions and a wide variety of tasks requiring independent judgment, ingenuity, and initiative.
  • Interacts with key members of the nursing team, physicians, and their staff, third party payers, state and federal agencies, auditors, and vendors.
  • Maintain a high degree of computer proficiency with MS Word and MS Excel.
  • Maintains all information in a manner such as to assure strict confidentiality and compliance with HIPPAA.
  • Other responsibilities assigned by the Director of Revenue Cycle.
 
REQUIREMENTS:                                                                                                                                  
  • Associate degree or equivalent experience.
  • Minimum of 2 years of case management and/or utilization review experience
  • Bachelor's Degree preferred.
  • Demonstrated knowledge of nursing home operations and CMS regulations
  • Strong problem-solving and advanced analytical skills necessary to read, understand, interpret, and analyze statistical data.
  • Excellent oral, written, organizational and interpersonal communication skills.
  • Ability to communicate effectively with senior leadership as well as other clinical/nonclinical directors, managers, staff, consultants, and third-party payers.
  • Demonstrate ability to effectively collaborate with peers and senior leadership on project assignments and group presentations.


*Acacia Network is an equal opportunity employer*

 
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