Case Management Director oversees a staff of case managers responsible for patient care coordination. Develops and implements case management programs, including utilization review, intake or discharge planning, and managed care contracting or negotiation. Being a Case Management Director evaluates patient care data to ensure that care is provided in accordance with clinical guidelines and organizational standards. Seeks treatments that balance clinical and financial concerns with the family's needs and the patient's quality of life. Additionally, Case Management Director contributes to the development and improvement of clinical care pathways that enhance cost effectiveness while providing quality care. Typically requires a bachelor's degree. Typically reports to top management. May require Registered Nurse (RN). The Case Management Director typically manages through subordinate managers and professionals in larger groups of moderate complexity. Provides input to strategic decisions that affect the functional area of responsibility. May give input into developing the budget. Capable of resolving escalated issues arising from operations and requiring coordination with other departments. To be a Case Management Director typically requires 3+ years of managerial experience. (Copyright 2024 Salary.com)
$10,000 Sign on Bonus for qualified Case Managers!
MAIN FUNCTION:
The Case Management (denial/prior auth) will review and appeal as appropriate for concurrent and retrospective authorization and denial activities for Arnot Health. Identify, track and trend, record and collect patient accounts denied by payer. Under the direction of the System Director of Care Coordination coordinates data with other Arnot Health departments and third party payers to discourage preventable denials.
DUTIES AND RESPONSIBILITIES:
1. Retrospectively determines medical necessity and appropriateness of admission and stay in accordance with InterQual Criteria to assist with appeal of denials
2. Maintains a working knowledge of the requirements of 3 rd party payers
3. Reviews denials from third party payers obtained from correspondence and or payments. Assists in tracking/trending by payer for denial reason items such as prior authorization, untimely filing, coordination of benefits, services type issues, and insurance or service verification. Identify patterns of common denial errors, types and recurring issues.
4. Facilitates, coordinates and prepares denial appeals working with internal and external customers in a proactive manner to bring satisfactory resolution in coordination with other department staff
5. Relays denial information to appropriate billing clerks and management.
6. Follow up on denial claims using reports to ensure completion of appeal with other department staff
7. Interacts with physicians and other Arnot Health departments in matters of auth/denial review decisions.
8. Maintains a working relationship with Physician Advisor regarding physician issues related to auths/denials.
9. Provide insurance companies with requested patient information as needed.
10. Maintains a working knowledge of programs necessary for denial management (ie: excel, word, QCPR, Sorian, InterQual, eCW)
11. Maintains files and all letters of non-coverage.
12. Tracks and trends denial activity in coordination with other department staff.
13. Maintains a working relationship with Finance and Corporate Compliance officers with regard to denial activity.
14. Is responsible for attending all mandatory annual educational programs as required by the position.
15. Employee understands and demonstrates the importance of satisfying the needs of the customer/patient by interacting with him/her in a friendly and caring way, being attentive to the customer’s needs, both psychologically and physically, and by taking the initiative to maintain communication with the customer in order to provide and secure and pleasant experience with the Arnot Health.
16. It is understood that this lists typical duties for the classification and is not to be considered inclusive of all duties that may be assigned.
MEETINGS:
Case management staff meetings. Case management staff development meetings. Auth/Denial Management meetings
EDUCATION:
RN required.
EXPERIENCE:
NYS licensed Registered Nurse required. Bachelor’s in nursing required. Must have proficient writing skills.
CARDIOPULMONARY RESUSCITATION (CPR) REQUIREMENTS:
Not required
PHYSICAL DEMANDS:
Routine office job. Light physical effort
EXPOSURE CATEGORY:
Category III. Tasks that involve no exposure to blood, body fluids or tissues. Category I tasks are not a condition of employment.
Location: 600 Roe Ave
USA
Elmira
NY
14905, Elmira, NY 14905
Job Type: Full-time
Pay: $84,375.00 - $107,227.00 per year
Benefits:
People with a criminal record are encouraged to apply
Education:
License/Certification:
Ability to Relocate:
Work Location: In person
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