Assistant, Case Management

Job Summary:

Responsible for providing technical and professional competence in supporting the Case Management Office located at Core Hospitals, Skilled Nursing Facilities (SNF) and Provider Service Center, to assist in the process of conveying information, tracking patients, and coordinating heath care services for our members as they transition across various care setting.

Essential Responsibilities:

Support the Case Management office with an emphasis on smooth transitions from care setting, e.g. in-basket messages, schedules follow-up KP center appointments for our members and our community services patients seen by KP physicians. Referral entry. Support Nursing staff with follow-up calls. Support nursing staff with trouble shooting services issues discovered during follow-up calls. Develops and maintains relationships with and among co-workers, external agencies and providers and various internal departments as they relate to the functioning of the referral management process as they relate to accessing services and coordination of care across transition. Support the nursing staff with the SNF and home care placement process. Copy and fax charts. Revises the hospital census reports from the previous and current day, and follows departmental procedures to expedite data entry/integrity and the discharge of our members across various care setting. Entry of inpatient hospital authorizations. (Including NICU). Arrange ambulance services for transport. Informs the hospital, facility, agency and business office of any member eligibility or coverage issues. Varies member eligibility and benefit coverage for various referral services. Determines applicability of coordination of benefits and ensure all appropriate payers sources are billed that includes Medicare, Workers Compensation, and co-coverage issues. Reviews with the manager and staff, eligibility or benefit clarification discrepancy. Serve as a contact person for obtaining and maintaining member information specific to transitional care services and communicates all relevant information to all required and coordinating within KP. Prepares and maintains data daily in the Health Care to report to facilities accurately hospital, e.g. RWB reports. Provides continuous telephone and clerical coverage for the CM office. Prepares and generate standardized or individual letters, memorandums, forms and materials associated with authorization and processing of hospital and referral services as needed under the direction of the Nurse. Participates in the orientation of new providers and staff regarding the referral management process. Keeps abreast of Kaiser Permanente and organizational policies and procedures which impact departmental operations, interprets and communicates them to physicians and other who are involved. Maintains current knowledge about, understands and follows state regulation requirements regarding benefits administration, case management and the use of specific guidelines and protocols. Perform other related duties as directed.

Qualifications:

Basic Qualifications:

Experience Minimum two (2) years of experience with Health Plan referral processing required. Education High School Diploma or General Education Development (GED) required.

License, Certification, Registration N/A Additional Requirements:

Knowledge of medical terminology, ICD-9 and CPT coding required.

Preferred Qualifications:

Two (2) years of utilization management experience preferred.