What are the responsibilities and job description for the Case Management Specialist position at Orthopedic One?
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POSITION SUMMARY
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Responsible for obtaining information or pre-certification required, ensuring that practice can be reimbursed for professional fees or facility fees associated with patient care. Documents information in written or electronic form as needed to ensure efficient workflow.
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RESPONSIBILITIES AND ACCOUNTABILITIES
- Pre-certification:
- Receives queries for pre-certification for diagnostic testing (MRI, EMG, CT, etc.), medication (Synvisc, NSAID, cox-2), surgery and physical or occupational therapy including documentation of ICD-10 and CPT codes.
- Contact insurance provider to obtain authorization numbers if pre-certification is required. If surgical procedures are involved, documents the days allowed for inpatients and sends information to appropriate hospital or surgery center.
- Generates pre-certification/authorization case management information in the EMR system noting authorization number, notes and date of service information. May also make relevant notes in patient information screens and apply information to surgery date of service or appointment.
- Generates reports from EMR to prompt a review for changes or cancellations one week prior to procedure.
- Provides phone coverage of the department hotline to support physician offices with same or next day requests or questions.
- Referrals:
- Receives referrals and enters information into EMR system including authorization numbers, primary care physician, visits allotted and expiration date or other notes pertaining to insurance plan.
- Prints physician schedules 24-48 hours in advance and reviews patient information for referrals to ensure it prints on encounter form for appointment.
- Researches missing information by contacting patient, PCP or insurance providers.
- BWC:
- Reviews appointment schedules 24 to 48 hours in advance for assigned physicians to identify worker's compensation patients.
- For new patients, reviews referrals and searches BWC web-site for claim number, allowed and billable information, ICD-10 codes, date of injury and other relevant information. For established patients, reviews BWC information for updates.
- Creates case information in EMR system for documentation purposes.
- Creates and maintains documentation as required for worker's compensation claims such as C-9, MEDCO 14, C-31, etc.
- Communicates with Managed Care Organization Case Managers as needed to obtain or provide information for treatment
- Customer Service and Communications:
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Communicates with patients, insurance carriers and other outside entities in a professional manner. Identifies solutions and responds professionally to patient concerns, i.e., pleasant tone of voice, courteous language, etc. Uses appropriate grammar and demonstrates tact and diplomacy in patient interactions, by phone and in person.
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Diffuses negative situations with patients and maintains a pleasant and professional tone during stressful circumstances and heavy workload.
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Communicates with staff members in a professional, pleasant manner; Shares information relevant to work, no gossiping or disparaging remarks, accepts work without complaint or provides reasons why assignment is unmanageable, asks and answers questions related to improving department performance
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- Pre-certification:
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TEAMWORK
- Teamwork:
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Willingly provides coverage, volunteers assistance, and maintains workflows within department as needed without direct instruction/supervision.
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Works cooperatively and refrains from participating in negative conversations.
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Shares knowledge and insights with co-workers in a constructive manner.
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Works to solve problems and address conflicts with appropriate person directly before involving leadership or uninvolved peers.
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Is considerate of others in the work environment with regard to taking breaks or meal periods, use of computer and phone, noise level in the department, etc.
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- Teamwork:
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POLICIES AND PROCEDURES
- Policies and Procedures
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Knows and complies with policies and procedures as enumerated in the Orthopedic One Employee Handbook and policies and procedures documents.
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Provides assistance and support to leadership in implementing policies and procedures as necessary.
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Actively participates in training, and conducting day to day work activity by adhering to all policies and procedures as enumerated in compliance and risk management programs.
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- Policies and Procedures
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QUALIFICATIONS
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Education, Experience, Certification and Licensure Requirements:
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High School Diploma or equivalent required. An Associate’s Degree in Medical Billing and Coding or Health Information Management is desirable but not required. Candidates must have a minimum of two years of medical billing experience which includes insurance authorization (prior authorization, pre-determinations, pre-certifications, etc.) and/or worker's compensation. Computer skills required to operate practice management system (i.e., use Window operating system, conduct Internet searches, communicate by email, etc.) Candidates must be able to tolerate a high volume of work while maintaining attention to detail and accuracy and demonstrate excellent oral and written communication skills.
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