This position is responsible for the initial review of all hospitalizations and telephonic concurrent review at outlying facilities; facilitating discharge planning and consultation with providers, the Medical Director, the Medical Affairs Manager and Case Managers on issues impacting the delivery of cost-effective quality health care, including referral to Case Management as required.
Nature & Scope
Implementation of the referral program including referral review, data gathering, provider education, data entry to maintain referral log and referral correspondence. Assists with Out-of-Network, Hospice, SNF, LTAC, etc.
The incumbent is responsible for the following:
1. Initiate the case management referral process and assisting with all case management activities.
• Receives and records initial referral notifications from providers or other referral sources, via telephone or facsimile. Screens and identifies potential case management candidates. Complete initial assessment forms, including verifying eligibility and contract benefits for all Enterprise lines of business.
• Communicates with Medical Management staff regarding potential case management candidates.
• Maintains Referral log.
• Assist Medical Management staff with the coordination and set-up of patients into case management. Including, but not limited to, follow-up telephone calls, patient chart set-up, data entry of pertinent information, and other clerical duties.
• Provide support for phone calls related to case management and claims review.
Medical Management Facilitator (Northwest Region)
2. Provide Medical Affairs Manager/Medical Director with support related to:
• Processing Administrative Authorization for claims payment.
• Coordinate appeal process for regional staff.
• Perform other duties as required.
3. Maintains and assures complete confidentiality in all aspects of job-related information.
4. Maintains positive working relationships with other employees in a team environment.
5. Participates in additional external training and educational programs.
6. Evaluates performance and creates plans for improvement.
7. Demonstrate the ability to work without direct supervision at times and organize one’s workflow to ensure timely response to project and/or inaquiries.
Minimum Job Requirements
Current LPN license in the State of Arkansas.
Pervious work experience in any of the following areas: home health, hospice, physician office or hospital setting.
Ability to use a PC with software (i.e., Microsoft Excel, Word, Access and PowerPoint)
Working knowledge of CPT, ICD codes, and medical terminology.
Strong skills in organization, oral and written communications.
This position is identified as level three (3). This position must ensure the security
and confidentiality of records and information to prevent substantial harm, embarrassment,
inconvenience, or unfairness to any individual on whom information is maintained.
The integrity of information must be maintained as outlined in the company Administrative
Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented
or detected on a timely basis by employees in the normal course of business. This
position must adhere to the segregation of duties guidelines in the Administrative
PRINCIPAL ACTIVITIES OR ACCOUNTABILITIES (Essential Functions of Job)
Arkansas Blue Cross and Blue Shield - 10 months ago
In 2012, Arkansas Blue Cross was named one of central Arkansas’ “Top Work Places” by the Arkansas Democrat-Gazette and...