What are the responsibilities and job description for the Certified Case Manager – Pre-Authorizations & Case Reviews position at PayerFusion Holdings LLC?
About Us:
We are a service-based company and as a licensed Third-Party Administrator, we are seeking only top talent and experienced personnel in order to meet and exceed our client's expectations. We’re an innovative company creating a unique experience for healthcare professionals. While many industry-wide solutions exist, nothing comes close to our ground-breaking approach.
Job Summary:
We are seeking a dedicated and detail-oriented Certified Case Manager to join our team. In this role, you will be responsible for preparing pre-authorizations for various medical services and conducting case reviews to ensure that all patient care plans align with medical guidelines and insurance requirements. You will work closely with healthcare providers, insurance companies, and patients to ensure a seamless process for approvals and reviews.
Key Responsibilities:
- Prepare and submit pre-authorization requests to insurance companies, ensuring all necessary documentation is included and follows the necessary guidelines.
- Review patient cases to ensure care plans are medically appropriate and align with insurance policies.
- Act as a liaison between healthcare providers, patients, and insurance companies to resolve any issues related to pre-authorization and care reviews.
- Maintain accurate and up-to-date records of all pre-authorization requests, approvals, and case reviews.
- Track the status of pre-authorization requests and ensure timely follow-ups.
- Analyze and interpret medical records and documentation to facilitate effective case reviews.
- Provide feedback and guidance to healthcare providers to ensure adherence to insurance requirements and proper documentation.
- Assist in the development and implementation of policies and procedures related to case management and pre-authorizations.
- Maintain confidentiality and adhere to all HIPAA guidelines.
Qualifications:
- Certified Case Manager (CCM) or equivalent certification required.
- A minimum of 5 years of experience in case management or a related healthcare field.
- Strong understanding of insurance processes, medical coding, and pre-authorization procedures.
- Excellent communication skills, with the ability to interact effectively with healthcare professionals, insurance companies, and patients.
- Strong attention to detail and organizational skills.
- Proficiency in using case management software and Microsoft Office Suite.
- Ability to handle multiple tasks and prioritize effectively in a fast-paced environment.
- Knowledge of HIPAA regulations and commitment to patient confidentiality.
Preferred Qualifications:
- Experience with TPA companies a plus.
- Previous experience in case review or utilization management.
Benefits:
- Excellent health and dental insurance coverage
- Free vision, life, and hospital gap insurance
- 12 paid holidays
- Paid Time Off
- 401K with company match up to 4%
