Case Management Coordinator

Summary

Provides support for the Case Management Department to include daily implementation of the Case Management Program and ensure that outpatient utilization is directed in a way that minimizes cost and maximizes quality and continuity in the standards set for by the UM and QM Committees. Assist Case Managers in coordinating services for high cost/high utilization cases so members obtain appropriate outpatient services to minimize inpatient utilization and avoid readmissions.

Duties and Responsibilities

• Demonstrates awareness of applicable current state, federal, and local laws and regulations.
  • Respects the dignity, confidentiality and privacy of each patient and adheres to HIPAA regulations and policies in relation to confidentiality of patient information that involves members, co-workers, etc.
  • Addresses case management customer service issues for Case Management Department.
  • Provides open, sensitive timely communication with patients, families, and their significant others to participate in the patient’s care.
  • Provides educational resources to the member and/or their family as appropriate.
• Initiates the “OPENING” of CM cases in ESSETTE case management database and documents the necessary data elements needed for CM review.
  • Maintains and updates database for case management.
  • Reviews and triages case management referrals, initiates case openings, verifies eligibility, processes and assigns cases to appropriate case manager.
• Maintains and updates ESSETTE database for Case Management Department in relation to CM cases as directed by the CM Manager including but not limited to:
  • Reviewing daily CM report for assigned PPG/IPA to target active cases which require further follow-up.
  • Contact member, family member, primary care, or specialty physician(s) on active cases with the objective to ensure member is compliant with recommended plan of care.
  • Follow-up on those referrals to ensure that specialty appointment date/time are kept by the member.
  • Coordinate case with Case manager including recognition of case management and risk management issues and/or diagnosis, and forwarding these cases to the appropriate case manager for follow-up.
  • Ensures utilization of in-network/contracted providers and vendors. Coordinates with UM Department the redirection of those cases identified as out of network/non-contracted providers and vendors.
• Responds to facilities and/or providers inquiring about an authorization request and generates authorizations for referral requests when directed to do so by the Case Manager including faxing of authorizations to vendors and follow-up with members if services are rendered in conjunction with discharge planning needs, such as home health, DME, Specialty consultation/follow-up, etc.
• Reports immediately to the Case Manager for any potential adverse issues identified in the course of performing duties and responsibilities to ensure appropriate corrective actions are implemented.
• Ensure timely completion of requests for medical records to communicate and obtain essential documentation from the provider and/or facility where active case is identified.
• Upon receipt of records obtained for CM cases, Coordinator will attach documents to the corresponding case via ESSETTE program and notify the Case Manager.
• Identify support systems from family and community resources. Assist the CM Department for assuring continuity of care between units within the hospital or between the hospital and other facilities or the home, by mobilizing resources necessary to assure a prompt discharge as soon as the hospital level of care is no longer necessary.
• Coordinates with the Case Manager to contact providers where there has been a delay in the delivery of services.
• Provide general clerical and administrative support services for care coordination.
• Assists the preparation of Health Plan audits in a timely fashion.
• Completion of ad hoc projects and other additional duties as assigned.

Minimum Job Requirements

High school graduate or GED. Medical Assistant with one (1) year experience in Managed Care preferred. Medical experience helpful, particularly as related to Medical Terminology, knowledge of ICD-10, CPT, and HCPCS coding. Minimum one (1) or more years of experience as a referral authorization coordinator/ specialist in an IPA/ Medical Group or Health Plan setting. Must be detail oriented and possess communication skills, both verbal and written. Must be computer literate with basic office and computer skills. Good interpersonal skills. Bilingual, EZ-CAP and ESSETTE knowledge a plus.