The Medical Services Care Coordinator is responsible for coordinating, integrating, and monitoring the use of medical and health care services for members, ensuring compliance with internal land external standards set by regulatory and accrediting entities. Refers appropriate cases to the Medical Director for review, identifies billing trends and refers possible medical fraud to the Special Investigations Unit. The Medical Services Care Coordinator may also perform a variety of technical and administrative tasks essential to the efficient operation of the Medical Services Department
• Performs clinical review of the appropriateness and quality of medical services, applying guidelines and medical policies and contractual benefits s well as State and Federal Mandates. May perform clinical review telephonically or on-site, depending on customer and departmental needs.
• Plans, implements, and documents utilization management activities which incorporate a thorough understanding of clinical nursing knowledge, coding standards, members’ specific health plan benefits, and efficient care delivery processes. Ensures compliance with corporate and departmental policy and procedure, identify and refer potential quality of care and utilization issues to Health Plan medical director.
• Utilizes appropriate communication techniques with members and providers to obtain medical information, assesses need for continuation of medical services, assists members in obtaining needed services, as appropriate, interacts with the treating physician or other providers of care.
• In support of the physician’s plan of care, provides care coordination for members who have immediate and long term medical care needs, identifies opportunities to integrate medical and health care services and implements those arrangements. Collaborates with hospital, home care, and other providers effectively to assure that clinical needs are met and that there are no gaps in care. Makes referrals into health promotion and health risk prevention programs as appropriate and member benefits permit.
• Acts as a resource and liaison to the provider community, explaining processes for accessing Health Plan to perform medical review, obtains case or disease management support, or otherwise interacts with Health Plan programs and services.
• Makes accurate and consistent interpretation of Interqual®, medical policy, contract benefits and State and Federal Mandates and maintains current and working knowledge of Utilization Management Standards.
• Performs pricing, coding and or medical necessity reviews prospectively, concurrently, and retrospectively ensuring compliance with internal and external standards set by regulatory and accrediting entities. Researches and adjudicates medical claims and contested cases to assure accurate application of contract benefits and Corporate Medical Policies.
• Accountable for meeting departmental guidelines for timeliness, production and metrics and meeting requirements established for Medical Services Audits to ensure adherence to regulatory and departmental policy/procedures.
• Maintains compliance with all regulatory and accrediting standards. Keeps abreast of changes and responsible for implementation and monitoring of requirements.
• Assists with training and special projects as assigned.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values and adhering to the Corporate Code of Conduct.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.
• Registered Nurse with current NYS license. Bachelor’s degree preferred.
• Minimum of three years of clinical nursing background required.
• A minimum of one year’s recent Utilization Management, ICU/ED or Home Care experience preferred.
• Must demonstrate proficient experience in use of a computer. Example-creating documents, Word, Excel, Internet and email.
• Experience in interpreting health plan benefit plans and strong knowledge of contracts & benefits preferred
• Knowledge of CPT, HCPCS and ICD9-CM diagnosis and procedure coding with eventual formal coding education and certification (i.e. CPC, CPC-H, RHIT) when indicated
• String written and verbal communication skills
• Knowledge of InterQual criteria and/or Medicare and Medicaid guidelines preferred.
• Ability to multi task and balance priorities.
• Must demonstrate work habits sufficient to be able to work independently on a daily basis.
• Ability to independently travel.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer
Excellus BlueCross BlueShield - 30+ days ago