Ancillary Services Case Manager

Why Choose Jefferson Health Plans? We are an award-winning, not-for-profit health maintenance organization offering Medicaid, Medicare, and Children’s Health Insurance Program (CHIP) plans that include special benefits to improve the health and wellness of our members. We are committed to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential. While this job currently provides a flexible remote option, due to in-office meetings, training as required, or other business needs, our employees are to be residents of PA or the nearby states of DE or NJ. Perks of JHP and why you will love it here: Competitive Compensation Packages, including 401(k) Savings Plan with Company Match and Profit Sharing  Flextime and Work-at-Home Options Benefits & Wellness Program including generous Time Off  Impact on the communities we service  We are seeking a talented and enthusiastic Ancillary Services Case Manager to join our team! General Description:   Work under general supervision to assure cost-effective, quality patient care management for DME, homecare, home infusion, hospice at home, shift care, medical day care, transportation, and outpatient rehab services (including waiver programs, occupational therapy, and speech therapy and physical therapy).   As the Ancillary Services Case Manager, your daily duties may include:  Process/review requests for durable medical equipment (DME), home care, home infusion, hospice at home, transportation, and outpatient rehab services such as occupational therapy, physical therapy, speech therapy shift care, and medical day care. Evaluate and authorize home care, home infusion, hospice at home, DME, transportation, and outpatient rehab requests for proper medical management and cost-effectiveness. Manage authorization requests received via 278 transactions via the provider portal and right fax queue Within the scope of required education and training, provide a clinical review for appropriateness of care. Utilization of InterQual criteria and Health Partners Criteria will be a source of review and standard for prior authorization. Coordinate with discharge planning, UM, and SNU to facilitate timely approval and coordination of services. Provide ongoing case management with a focus on preventing admissions and ER visits. Provide written and oral communication to members and providers for approvals/denial of services. Select and complete with appropriate language letters to providers and members. Track assigned cases for timely reviews/updates and ensure decisions are reflected in case documentation. Identify duplication of services and opportunities for improvement. Function as a liaison between ancillary providers and members Provide telephone service promptly and courteously.  Consults with Medical Directors for medical director review and medical necessity determinations. Meet specified timeframes established by regulators (DHS, NCQA, DOH, and CMS). Identify expanded and continuity of care services and track them for the transition of care. Accurately code all services using appropriate ICD-10, CPT, and HCPCS coding systems. Serves as liaison to customer service representatives, grievance & appeals staff, and other internal staff departments. Assists and supports all related processes, including developing policies, procedures, and process improvement efforts as assigned. Participate in on-call program   Qualifications  Current Pennsylvania State RN  2 year’s clinical nursing experience. Homecare and outpatient rehab services experience preferred.  Experience working in managed care environment preferred.  Experience with Medicare/Medicaid populations a plus.     Skills, We Value:  Knowledge of medical necessity principles, including clinical criteria Knowledge of InterQual Computer literacy, including familiarity with Windows and Microsoft Office programs Ability to work independently Ability to work efficiently, with excellent time management skills Excellent communication skills both verbal and written Ability to work well with all types of providers/members Ability to maintain professional demeanor and confidentiality Sensitivity to the needs of every individual to be treated with respect and fairness