care manager Los Angeles, CA
Job description
If you are interested apply online and send your resume to [email protected]
POSITION SUMMARY
The Care Coordinator of Utilization Review (UR) function as a support liaisons for the e-TAR process. Coordinates care submission relating to the process of health care utilization from the point of patient admission to discharge. Processes will include arrangement and coordination of documentation for inpatient admissions with continued and extended hospital stays, and discharge review that determine medical necessity. The care coordinator of utilization review adjuncts the assurance of high quality care and efficiency of utilization available through healthcare resources, facilities, and services substantiating health plan reimbursement categories. This role communicates with the interdisciplinary care team to support the UR process and care management criteria.
ESSENTIAL DUTIES AND RESPONSIBILITIES
1. Daily coordination of support documents pertaining to the DNFB List of Medi-Cal patients.
2. Ensures completion of patient records and attachments prior to submitting them to Medi-Cal via e-TAR.
3. Assist with tracking submitted e-TARS to ensure deferrals and denials are followed-up within a timely fashion.
4. Reports e-TAR support progress and delays to manager of care management.
5. Participates in interdisciplinary team and department of revenue meetings to discuss e-TAR workflow, documentation necessity (attachments), process improvement, and submission timeliness.
6. Collaborates with interdisciplinary team participants in team rounds to: (1) facilitate timely care, (2) assures quality of care throughout the hospital stay, and (3) minimizes adverse outcomes.
7. Assists with the initiation of appropriate referrals to the internal interdisciplinary team and outside provider networks (health plans, IPAs, and FQHCs) as indicated.
8. Communicates with admitting or PFS regarding the needs of the patient, payer, and provider documentation.
9. Patient needs are supported within the limitations of the existing individual beneficiary care structure.
10. Communicates relevant elements of the health plan benefits.
11. Documents and reviews all team member, physician, and patient/family communications and concerns pertaining to coordination of care and services.
12. Screens every patient chart to justify identified needs for assessments, documentation of medical necessity, and/or discharge planning needs.
13. Adheres to the Care Management Department policies and procedures.
14. Participates in the Quality and Performance Improvement Plan for the Care Management Department.
15. Considers the patient population served, age-specific criteria and the Jean Watson Model of Care in all patient/family care and interaction.
16. Collaborates with on-site care management team to support best practice guidelines.
17. Attends unit/department staff meetings as well as other meetings as assigned.
18. Acts as a liaison between the facility and payers ensuring timely notification of patient admissions.
19. Completes daily faxing of all clinical reviews to payers ensuring proper authorization as well as notifying the care manager of any patient denials accelerating the case for peer to peer.
20. Maintain fax payer system with correct and up to date numbers to avoid HIPAA breaches.
Other duties as assigned.
POSITION REQUIREMENTS
A. Education
- High School Diploma/ GED equivalent required
- Some college preferred-medical focus
B. Qualifications/Experience
- 1-2 years healthcare facility experience and familiarity preferred.
- A team player that can follow a system and protocol to achieve a common goal
- Highly organized and well developed oral and written communication skills
- Confidence to communicate and outreach to other community health care organizations and personnel
- Demonstrates sound judgment, decision making and problem solving skills
C. Special Skills/Knowledge
- Bilingual language skills preferred (Spanish)
- Basic computer skills
- Current Basic Life Support (BLS)
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