Case Management Authorizaiton Specialist I

Overview

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At Emory Healthcare we fuel your professional journey with better benefits, valuable resources, ongoing mentorship and leadership programs for all types of jobs, and a supportive environment that enables you to reach new heights in your career and be what you want to be. We provide:

• Comprehensive health benefits that start day 1

• Student Loan Repayment Assistance & Reimbursement Programs

• Family-focused benefits

• Wellness incentives

• Ongoing mentorship, development, leadership programs

• And more

Description

JOB DESCRIPTION:

• The Case Management Authorization Specialist (CMAS) Follows developed policies and procedures to obtain insurance eligibility and benefits by identifying correct insurance plan and determining coordination of benefits with minimal guidance.

• The CMA is responsible for informing the care team and financial counseling of any discrepancies identified related to coordination of benefits and/or coverage as it relates to ineligible coverage, non-covered services or out of network status.

• Secondary to verification of eligibility, the CMA provides notification of admission for inpatient and observation stays to the identified payor within the payors required timeframe in order to secure reimbursement for services provided.

• Upon completion of notification of admission, the CMA is responsible for confirming clinical authorization by communicating patient and clinical information, medical necessity, and level of care to payors to secure account for reimbursement by following payors established guidelines as it relates to clinical authorization and review.

• The CMAS is responsible for reconciliation of clinical days authorized versus patient actual days in order to secure reimbursement for provided care.

• The CMAS is responsible for communication with the payors for any pending or incomplete notifications/cases and holds the ultimate responsibility of resolving any incomplete authorizations, no greater than 7 days post notification.

• The CMAS is able to initiate and follow up on retroactive authorization requests as directed.

• The CMAS functions with minimal oversight and guidance and with a general understanding of payor requirements as it relates to insurance verification, notification, and authorization.

• Case Management Specialist may specialize in certain payors but overall a generalist within the department.

• The CMA assists with providing technical and clerical support, as directed, to the Case Management team in order to timely transition patients into post-acute services within the allotted amount of reimbursable hospital days, as determined by the clinical authorization obtained.

• Facilitates referral process, as directed, for securing post-acute care services which can include: Home health, Durable Medical Equipment, Rehab, Hospice, Long Term Care, and transportation.

• The CMAS will collaborate with insurance case managers to initiate/request authorizations for post-acute care.

• The CMAS will have a general understanding of navigating out of network coverage for post acute services.

• The CMAS ensures regulatory requirements are met as it relates to the MOON and IMM.

• The CMAS prioritizes work with minimal guidance for optimal reimbursement and to avoid financial risk to both patient and hospital.

• Ability to multi task in a fast paced environment while efficiently handing multiple priorities and ensuring deadlines are met.

• The Case Management Authorization Specialist will ensure proper use of Case Management Systems and display adherence with workflows.

• Meeting all quality and productivity expectations.

• Successful completion of yearly competencies.

• Must obtain 4 CEU credits per year, related directly to core job functions, in addition to yearly competencies.

• Actively participates in process improvement initiatives by sharing thoughts and ideas in a constructive manner.

MINIMUM REQUIREMENTS:

• High school education diploma or equivalent.

• College degree preferred.

• At least two years of experience in a healthcare setting is required.

• Two (2) years of insurance verification, authorization, or related work preferred.

Additional Details

Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law.

Emory Healthcare is committed to providing reasonable accommodations to qualified individuals with disabilities upon request. Please contact Emory Healthcare’s Human Resources at [email protected]. Please note that one week's advance notice is preferred.