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Day - 08 Hour (United States of America)
This is a Stanford Health Care Tri-Valley job.
Job Summary
The Case Management (CM) Liaison Lead serves as a liaison between the SHC-TV UM/CM team and Health plans. Will serve as a resource to the UM/CM team members and is responsible for processing authorizations within the scope of their assignment and will oversee the CM Liaison Team in the daily operations.
Essential Functions
- Utilize knowledge and experience to analyze contractual or administrative issues related to the requests.
- Identify additional information needed and the ability to research and understand benefits and criteria.
- Accurately identify when and how to refer cases to appropriate clinical personnel or take other actions as necessary or required.
- Coordinate with other insurance coordinators and the medical review staff.
- Forwards all requests that require additional clinical review to determine medical necessity criteria to the pre-authorization nurse for determination.
- Work independently and in collaboration with the clinical UM team members with timely completion of the UM/CM WQ for ADT, Rooming, Medical necessity, and Quality assurance.
- Assist the clinical UM team in validating the physician orders and ensure admission is coded correctly.
- Manages denial appeals. Prepares, assists the clinical UM team for review, submits within deadlines and follows up on outcome.
- Develops and maintains the system to oversee all prior authorization and ensures that clinical information is completed in a timely and accurate manner.
- Stays in contact with CM/UM department to ensure clinical interventions are handled properly.
- Oversee the CM Liaison Team in the daily operations.
- Assist with the API and Staffing schedule.
- Responsible for ordering medical and non-medical supplies and transportation vouchers for the department.
- Contributes to the efficiency of the department by being flexible and cross-trained on other functions.
- Works on a variety of special projects and assumes other duties as assigned by the UM Director and CM Team leaders.
- Employee must perform all duties and responsibilities in accordance with the C-I-CARE Standards of the Hospital. C-I-CARE is the foundation of Stanford Healthcare – Tri-Valley’s patient-experience and represents a framework for patient-centered interactions
Job Qualifications
Education
- High school diploma required.
Experience
- A minimum of one (1) year of experience as a Case Management Liaison required.
- Experience with payer authorizations and knowledge of Utilization Management in an acute hospital setting required.
- Basic Life Support Certification required.
Knowledge, Skills, and Abilities
- Ability to make sound judgment
- Excellent communication and interpersonal skills
- Ability to work independently and function effectively as a member of an interdisciplinary team.
- Basic Computer skills required.
- Strong advocacy and problem-solving skills
- Strong attention to detail
- Knowledge of acute care in relation to safety, security, and Joint Commission standards
Physical Demand and Working Conditions
The Physical Requirements and Working Conditions in which the job is typically performed are available from the Occupational Health Department. Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the job.
Equal Opportunity Employer
Equal Opportunity Employer Stanford Health Care – Tri-Valley (SHCTV) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements
Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.
Base Pay Scale: Generally starting at $31.94 - $41.20 per hour
The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.
