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The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

What You Will Do
To coordinates the completion of referrals for medical care and complex requests, including requests for outpatient care, elective inpatient admission, skilled nursing facility (SNF) admission, medical equipment (DME), home health, and transportation and prescription authorization in accordance with Sharp Rees-Stealy Medical Group (SRS) referral guidelines. To provide support and facilitation of care coordination services provided by the Case Managers to members.

Required Qualifications

Other : successful completion of ICD and CPT coding classes, or equivalent work experience.
3 Years working in the managed health care field, preferably HMO or delegated risk medical group/IPA setting.
1 Year experience with medical coding and data entry, preferably in a managed care environment.

Preferred Qualifications

Other : successful completion of Medical Assistant Program or equivalent.

Essential Functions

Assess the need for health care resources and insurance
Obtain detailed benefit coverage for specified plan member.
Check eligibility status.
Investigate and follow-up on all eligibility issues in accordance with health plan and SRS guidelines.
Department support
Maintain and organize data, prepare and distribute reports within designated timeframe.
Manage correspondence to members and PCP, health plans and other service providers.
Make phone calls to members, physician offices, health plans, and providers to assist in care coordination under the guidance of case managers.
Organize and maintain case files.
Provide clerical support and assistance to the Case Management team.
Contributes to the continuous improvement initiatives of the Case Management team to deliver quality interventions timely.
Maintain data, run reports in an organized and timely manner.
Completion of daily EA census, spreadsheet tracking, email notifications, office supply monitoring, maintain data and run department reports in an organized and timely manner.
Organize and implement daily work plan for designated facility.
Industry skills and competency
Obtain detailed benefit coverage for the more complex requests for service specific to member plan coverage.
Apply the principles of the medical group guidelines and Health Plan benefit guidelines to approve referrals designated at the Care Specialist level.
Investigate and follow-up on all eligibility issues in accordance with health plan and medical group guidelines.
Classify patients into full risk/shared risk grouping according to the Division of Financial Risk.
Identification of "Third Party Liability" (TPL) cases, completion of TPL form and forwarding of information to appropriate department/patients.
Process referrals for prior authorization
Responsible for submission of electronic Prior Auth referrals from generation, approval (at CS level) and acquisition.
Obtains necessary medical information for use by themselves, Medical Directors, the Hospitalist Physician and/or Case Manager.
Identifies and refer requests for review by higher level staff (Medical Director, Hospitalist or CM) within department turn-around time (TAT) standards.
Researches and assists in the denial process - gathers documentation after review by medical director, ensure that all information is complete, assesses and selects the appropriate denial reason. Maintain mandated TAT for denials.
Research and assist in the appeal process; gather documentation, ensure packet is complete and sent within appeal period.
Gathers clinical information from multiple sources including use of Sharp and/or Hospital applications to retrieve patient medical records for review by Case Managers.
Verifies and documents eligibility and benefit details.
Applies specific health plan criteria and/or guidelines to all prior authorization requests.
Professional development
Actively identifies gaps in skills and competencies and participates in seminars/classes to enhance gaps.
Attends and actively participates in department/team process/quality improvement activities.
Attends required training as scheduled by leadership team.

Knowledge, Skills, and Abilities

Proficient in medical terminology and current standards of clinical practice.
Proficient in use of ICD (current version), CPT and HCPC coding systems.
Proficient in typing and computer data entry.
Excellent organizational and time management skills including the ability to multitask. Excellent analytical and problem solving skills.
Excellent verbal and written communication skills.
Ability to read, speak and hear English clearly.
Ability to work independently in research and decision making with minimal direction from higher-level staff.
Travel between Sharp HealthCare facilities and corporate office is required; must have own transportation with adequate insurance or the ability to travel between facilities.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class

Other; Other

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