Job Summary :

Responsible for supporting all non-clinical functions throughout the Continuum. Supports daily activities of Case Managers and Physicians.

Ensures data integrity related to all applicable in-scope inpatient and outpatient services. Coordinates data input, analysis, and reporting for KPGA Continuum utilization management, continuing care services, case management, and outside services management.

Essential Responsibilities :

• Supports all non-clinical functions throughout the Continuum.
• Facilitates discharge planning for members across the Continuum.
• Answers phones to respond to all inquiries made by patients, vendors, and other healthcare recipients. Must be able to handle at least 100-150 calls per day.
• Must be able to work in a call centric environment and meet daily metrics.
• Must be able to work in a productivity driven environment to meet the need of members and providers.
• Enters authorization / referral data into required applications for all levels of care, ensuring the correct admitting, principal, and discharge diagnoses, bed types, discharge date, and other applicable fields.
• Ensures accuracy of Tapestry Census Reports by reviewing / updating authorizations daily and attending case management rounds to update diagnoses or other information as needed or indicated.
• Documents outside medical services and enters referrals into Tapestry for all applicable levels of care.
• Ascertains eligibility and benefits for all admissions and every 7 days thereafter (or other designated time frame).
• Ascertains admission status via physician order for weekend retro admissions, enters authorization, and sends to CM / UM for review.
• Coordinates data and reporting needs, data collection process, and data processing issues; provides timely utilization data and analytic support.
• Collaborates with other organizational units and outside facilities to obtain, verify, and / or provide information, e.

g. works with KP Claims and external vendors to reconcile billed charges.

• Answers inquiries and educates members, physicians, and hospitals on covered benefits and other related topics.
• Provides information and assistance to members during claims review process and coordinators authorized and non-authorized claims review.
• Coordinates and supervises air and ground transportation and authorization review for said services.
• Coordinates durable medical equipment for members.
• Maintain the consistency and integrity of all applicable utilization tracking management systems.
• Schedules member appointments and coordinates care as needed.
• Determine admission status via MD order for weekend retro admissions, enter authorization & forward to ICM for review.
• Work pended claims in Tapestry pool, forwards to appropriate Continuum staff for investigation as needed and pend back to claims pool when completed.
• Run, print, and make copies of Tapestry census for rounds. Attend case rounds with Continuum staff & Physicians.
• Copy required sections of members charts for referrals to all levels of care and place on front of chart as requested by Case Manager / Utilization Reviewer.

Basic Qualifications :

Experience

Minimum two (2) years of relevant experience.

Education

High School Diploma or General Education Development (GED) required.

License, Certification, Registration

Certified Professional Coder within 6 months of hire OR Certified Outpatient Coder within 6 months of hire OR Certified Coding Specialist within 6 months of hire

Additional Requirements :

• Able to apply critical thinking, analytic techniques, problem solving, and computer skills to all inpatient and outpatient data.
• Strong analytic and communication skills (written and verbal)
• Expertise with tracking, spreadsheets, and graphic computer systems operating on PC mainframes.
• Knowledge of health plan benefits
• Understanding of medical center operations, complex health systems, with the ability to quickly grasp and apply policies and procedures.
• Data entry experience.
• Working knowledge and use of the most up-to-date ICD manual, as well as CPT / HCPCS codes.
• Understanding of health care payment mechanisms (capitation, fee-for-service, etc.)
• Functional knowledge of computers, fax machines, and copiers.
• Excellent customer service skills.
• Proficient with Microsoft Office Suite (Word, Excel, PowerPoint, etc.).

• Clinical background preferred.
• Medical Terminology Certification preferred.
• Bachelors degree.

Last updated : 2024-08-14