Change Management Specialist jobs in Gainesville, FL

The Case Management Specialist is responsible for obtaining inpatient/observation authorizations for commercial payers. Provides clinical updates to commercial payers and communicates discharge planning updates when requested. Initiates Peer to Peer discussions with Insurance companies as appropriate. Provides administrative and clerical support to the Case Management Director and Case management team including assisting with audits, reports, and data collection. Assists in the coordination of daily activities and projects. Coordinates the flow of information between the Case Managers, Admitting, Business Office and insurance companies. Maintains denial log and works with the Shared Service Center regarding denial management. Participates in data collection projects and compiles data for presentation to Director, CFO, CEO and Physicians Committees. Manages the EQH process to ensure authorizations are obtained. Demonstrates a working understanding of federal and state regulations, departmental policies, particularly those related to discharge planning and utilization review

Responsible for operational oversight of the CM Department , including but not limited to: Answers telephones, coordinates meetings, maintains filing systems and logs and schedules appointments as needed.. Orders all departmental supplies via Lawson system. Serves as a mentor to Patient Navigator.

Manages the authorization and approval process for all Non-Medicare payers. Works with CM’s to ensure patients are in the appropriate level of care, so as to maximize facility reimbursement. In direct contact with payers to ensure initial clinical documentation is received and provides additional information when requested

Manages the Concurrent review process for all insurances to ensure updated reviews are provided and additional days are authorized. Provides retro-reviews upon request.

Maintains current knowledge on insurance plans and reimbursement mechanisms. Revises insurance contact list as needed and provides copies to all staff when revisions are made.

Conducts secondary audit via Cerner Rev Cycle prior to account close-out and verifies critical components are met; and discharges are documented. Corrects any/all discrepancies prior to closing out account. 6. Monitors and provides clinical documentation to payers for labor and delivery admissions.

Completes PACT audits for Medicare and Medicare Advantage claims

Manages the denial process. Prior to denial, as a last resort, works directly with payers to provide requested documentation and/or coordinate P2P’s. Provides denial and clinical documentation to corporate appeals team. Tracks and trends denial data by entering into Cerner “Rev Cycle”, and provides to senior management for process improvement opportunities.

Gathers, analyzes, and interprets, in various formats, department data and reports this information to the Dir CM and senior management. This data is used for process improvement opportunities and is a direct correlation of our HCAHPS scores.

Maintains Revenue Cycle Work list and works with CM Director to ensure that all items are completed. Communicates with PAU (Pre-Arrival unit), SSC and billing/registration departments regarding patient accounts.

Reviews accounts for possible adjustments due to non-payment and/or denials and coordinates with CBO to adjust and rebill.

Communicates downgrades, changes, and/or corrections on patient accounts to SSC-Sarasota, Coding, and Billing to ensure claims are billed correctly to avoid penalties.

Manages the EQH process for the newborn babies to ensure authorizations are obtained. Enters clinical information and obtains authorization for all retrospective reviews.

Assist with concurrent insurance reviews when needed.

Attends monthly staff meetings and Departmental /Administrative huddles as requested by CM Director.

Attends monthly Denial Meetings, takes notes and completes minutes.

• Education: High School Diploma required. Associates or Bachelor's Degree preferred
• Experience: Minimum 1 year administrative experience required. Medical office, hospital, or insurance authorization experience preferred.

Experience

• 1 year(s): Minimum 1 year administrative experience required. Medical office, hospital, or insurance authorization experience preferred.

Education

• High School or better