Job Summary

The Managed Care Specialist serves as the managed care liaison by submitting clinical information and obtaining managed care authorizations for acute care patients through communication with representatives of managed care organizations. Collaborates with Unit Based Case Managers and/or Physicians to determine acute care criteria prior to contacting managed care organizations. Knowledgeable of all payor notification requirements. Works with Patient Accounting Department for resolution of payor reimbursement issues. Facilitates denial management by working with the Physician Advisor and the Denial Managers to ensure appropriate documentation of activities to maximize positive financial outcomes.

Essential Job Functions

• Managed Care Liaison
  • Conducts electronic and telephonic reviews (admission, continued stay, and retrospective reviews) with managed care organizations for urgent or unplanned acute care patient admissions to secure payor authorization and subsequent reimbursement for clinical services. Documents and communicates authorization and need for continued stay reviews to the Unit Based Case Manager for all admissions. Communicates all payor determinations to Patient Accounting via Star and other information systems as needed.
  • Communicates and documents adverse payor determinations in a timely manner to the appropriate CRM staff member and assists with the appeal process as required.
  • Documents payor/authorization information into Star, Care Manager, and other hospital systems as required.
  • Identifies potential problems with securing authorization and seeks resolution with the Unit Based Case Manager and Department Manager.
  • Collaborates with Pre-Admission office to verify appropriate bedding of incoming patients and assures that pre-admission authorizations are obtained.
  • Collaborates with Patient Accounting Department and other ancillary departments for up to date payor information and their contact number(s).
  • Provides patient demographics to managed care companies daily for required financial classes.
• Utilization Management
  • Possesses current and accurate working knowledge of InterQual Level of Care Criteria and other criteria as necessary to receive acute inpatient approval of a specific patient's case.
  • Communicates any changes pertaining to criteria to all appropriate parties.
  • Performs retrospective reviews on discharged patients requiring certification, including but not limited to late Medical Assistance pick-ups, new Medical Assistance beneficiaries, and urgent/unplanned admissions/discharges from the weekend. Confers with all physicians prior to third party payor interface.
  • Communicates pay class changes to unit based case manager on concurrent patients, assists denial specialist with post-discharge pay class changes.
  • Communicates regularly with other departments who impact payor information and changes to patient information related to payor source.
  • Keeps updated list of payor contacts and communicates this information to CRM staff in a timely manner.
  • Assists Case Managers by being a resource person for payor specific timeframes from authorization/certification.
  • Serves as a resource for the unit based Case Managers on medical necessity, ensuring their reviews are comprehensive and complete concurrent cases.
  • Maintains current data base tracking closed out cases and placing patient authorizations into STAR for all third party payors requiring certification.
• Denial Management
  • Initiates contact with Attending Physician and Physician Advisior on retrospective cases for clarification of intent.
  • Notifies the Denial Management Specialist of all real or potential cases in which an adverse determination has been rendered or is anticipated by the payor.
  • Tracks denials and refers to the Denial management Specialist if decision is still outstanding from the payor.
  • Maintains patients' rights by adhering to HIPPA and other regulatory agency requirements.
• Maintains current denial daily data base and prints denial sheets out daily for the Manager to review with staff the following morning.
• Maintains a weekly database of the Failed Bill and is responsible for keeping this to the minimum amount possible.

Required Qualifications

• Graduate of accredited nursing program.
• Two (2) years of acute care clinical nursing experience or case management/utilization review experience.

• Knowledge of Payor/Insurance Benefits
• Knowledge of basic Office Equipment such as copier, fax machine, etc.
• Strong Analytical, Data Management and PC skills.
• Ability to work independently and exercise sound judgement in interactions with payors, physicians, and other members of the health care team.

• Strong leadership ability, good organizational skills, independent and critical thinking skills, sound judgment
• Strong ability to communicate complex and/or controversial topics and concepts to a wide and diverse audience.

Preferred Qualifications

• Working knowledge of Performance Improvement concepts.
• One (1) to two (2) years of case management or utilization review experience preferred.
• Case Management Certification
• Working knowledge of InterQual Level of Care Criteria, utilization management and reimbursement guidelines

License, Certification & Clearances

• Current licensure to practice as a Registered Nurse in the State of Pennsylvania.
• Act 34-PA Criminal Record Check from the PA State Police system

Supervisory Responsibilities

• This position has no direct supervisory responsibilities, but does serve as a coach and mentor for other positions in the department.

Position Type/Expected Hours of Work

• Incumbent will be scheduled based on operational needs ( weekdays, weekends, etc.).
• Travel may be expected locally between Excela Health locations.

LEAN

• Actively promotes a Lean work culture by performing team member duties to encourage consistent use of LEAN principles and processes, including continually seeking work process improvements. Recognizes the necessity of taking ownership of one’s own motivation, morale, performance and professional development. Strives for behavior consistent with being committed to Excela’s missions, vision and values.

AAP/EEO

• Excela Health is an Equal Opportunity Employer. It is the policy of Excela Health to prohibit discrimination of any type and to afford equal employment opportunities to employees and applicants, without regard to race, color, religion, sex, national origin, age, marital status, non-job related disability, veteran status, or genetic information, or any other protected class. Excela Health will conform to the spirit as well as the letter of all applicable laws and regulations.
• Ability to perform the Essential Functions listed on the Physical Conditions and ability to perform the Essential Functions on the Working Condition chart below.

Work Environment

Effective March 2020 or during pandemic: goggles, face shield and mask are required according to CDC guidelines

Physical Demands

When lift requirement is in excess of 50#, lift assistance (2 person) and/or transfer device is required.

Skills

Required

Required