Managed Care Coordinator I Jobs

Authorization Evaluation (Intermediate): Possesses sufficient knowledge, training, and experience to role model and coach less experienced peers.

Confer with other MCC's, brainstorm on any new payer process changes, and update Payer Auth Requirement document

The responsibilities listed are a general overview of the position and additional duties may be assigned.

Obtain Start of Care (SOC) authorization.

Obtain Add-on prior authorization, obtain prior authorization for Resumption of Care (ROC), obtain concurrent authorization.

Review written off no authorization (wona) requests from billing team for possible.

Knowledge of standards in managed care credentialing practiced, health plan credentialing requirements, statistics, data collection, analysis and data presentation

Excellent interpersonal communication, organizational and problem-solving skills.

Responsible for leading the activities associated with coordinating, monitoring and maintaining the credentialing and re-credentialing process.

Proficient in computer applications (e.g. Windows, Microsoft Office, Internet browsers, medical staff/credentialing software databases, etc.)

Knowledge of all regulatory requirements and internal processes to ensure that all maintenance and contractual documents are managed to expectations

Minimum of one (1) year of experience in a managed care or healthcare organization or contract development and review is required

Prior experience with provider documents and provider data entry is highly preferred

Perform any other job duties as requested

Intermediate computer skills including Microsoft Word, Excel and Outlook

Critical listening and thinking skills

Specific education and years and type of experience may be required based upon state law and contract requirements.

Uses appropriate screening criteria knowledge and clinical judgment to assess member needs.

For MMP, requires Community Health Worker certification to be obtained within one year of employment.

QMHP Certification of MA/MS in Social Work, Counseling, or a related behavioral health field preferred.

Conducts assessments to identify individual needs and develops care plan to address objectives and goals as identified during assessment.

Monitors and evaluates effectiveness of care plan and modifies plan as needed.

Preferred Work Experience: 7 years-healthcare program management.

Job title: Managed CareCoordinator II (Remote)

Preferred Licenses and Certificates: Case Manager certification, clinical certification in specialty area.

Note: 1st week of onsite training then remote.

Preferred Education: Bachelor's degree- Nursing.

5% Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.

Primary duties may include but are not limited to: Uses appropriate screening criteria knowledge and clinical judgment to assess member needs.

Experience working in the Foster Care system.

QMHP certification or MA/MS in social work, counseling, or a related behavioral health field preferred.

Working with youth 0-26 in the foster care system/former foster care system.

Conducts assessments to identify individual needs and develops care plan to address objectives and goals as identified during assessment.

Monitors and evaluates effectiveness of care plan and modifies plan as needed.

General Knowledge, Skills & Abilities

Updates Sales and Account Management on Direction of Care rules and changes throughout the year

Bachelor’s Degree in Business or related field or the equivalent combination of education, training, and work experience.

Requires working knowledge of managed care services in the workers’ comp industry including bill review, PPOs, and direction of care rules.

Opportunities to work from home

Tuition Reimbursement Program including certifications

Maintain an in-depth knowledge of our products, both existing and new

1+ years of customer service experience

Experience with CRM and ERP systems preferred

Critical thinking, analytical, research and problem-solving skills

Answer inbound calls, emails, and web inquiries using the first-contact resolution process while maintaining department quality and production metrics

Document all customer interactions and conversations in the appropriate Pulse CRM fields and update pertinent information into Oracle order notes

Must have critical thinking skills and maintain confidentiality.

Excellent organizational skills and ability to handle a variety of tasks simultaneously.

Knowledge of medical terminology and/or behavioral health topics.

Strong decision making and prioritization skills.

Strong patient engagement, interpersonal, and communication skills and ability to establish a therapeutic relationship with the patient.

BA/BS/BSW in health related field with one year of experience working in community health.

General Knowledge, Skills & Abilities

Creates purchase order(s) per One Call Care Management’s nursing department procedure to authorize additional or continuation of service(s) to provider.

Notifies appropriate One Call Care Management’s department(s) of referrals requiring their expertise.

Performs special projects as assigned and prioritized by management.

Opportunities to work from home

Tuition Reimbursement Program including certifications

Primary liaison between marketing liaisons, facilities admissions and MCO Case Management for new referrals and readmissions.

Communicates and maintains effective working relationships with marketing teams, facility contacts, and case management team as relates to referral process.

Able to hold facilities accountable to adhere to the process for referrals to case management of MCO cases.

Assistant to Case Management Consultant - Obtaining Auth, communication with communities, and communication with insurance companies.

Experience working in a skilled nursing facility

Performs review of referral requests for completeness of information and determines when ready to move to a case manager for preauthorization.

Identifies and makes referrals to appropriate area/staff (Medical Director, Subrogation, Quality of Care, Case Management, etc.).

Continuing education funds for additional certifications and certification renewal

Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.

Provides education to members and their families/caregivers.

Supports the discharge planning process by assisting and collaborating with Managed Care Coordinators as appropriate.

Maintains current knowledge of contracts and network status of all service providers and applies appropriately.

Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans.

Promotes enrollment in care management programs and/or health and disease management programs.

Seven years healthcare program management.

Thorough knowledge/understanding of claims/coding analysis, requirements, and processes.

Case Manager certification, clinical certification in specialty.

Continuing education funds for additional certifications and certification renewal

Passionate about working in a healthcare setting and committed to delivering a best-in-class patient experience

A high school diploma/GED is required plus one year of relevant experience

Experience in customer/patient service is strongly preferred

A proven dedication to healthcare through work, internship, or volunteer experience

An effective communicator, capable of determining how best to reach different audiences and implementing communications based on that understanding

Adept at building partnerships and working collaboratively with a team to meet shared objectives and goals

Updates Sales and Account Management on Direction of Care rules and changes throughout the year

Bachelor’s Degree in Business or related field or the equivalent combination of education, training, and work experience.

Requires working knowledge of managed care services in the workers’ comp industry including bill review, PPOs, and direction of care rules.

Opportunities to work from home

Tuition Reimbursement Program including certifications

Manage provider network data extracts and workflows related to MCO participation

Equivalent experience will be accepted in lieu of the required degree or diploma.

2 years recent relevant experience.

This position is work from home eligible.

*Occasional on-site meetings and office practice site visits*

Pay Range: $39.59 - $59.38 / hour

Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

Knowledge of VPNs and remote desktops.

Healthcare background is required, preferred to have knowledge in revenue cycle.

Excellent interpersonal skills are necessary to develop strong working relationships with internal and external contact.

Experience with various electronic medical records and understand HIPAA and PHI privacy and security.

Must be able to pass as skills assessment exam, comprehensive and background check.

Exhibits effective and independent decision-making skills and can follow oral and written instruction or direction.

Manage and facilitate bi-weekly and monthly meetings with Apria management/branches and Account representatives/service areas to ensure proper relationships are maintained.

Assist branches in management of closet inventory and coordinate services with subcontracted vendors.

Education or experience equivalent to a four year college degree is required.

Comprehensive benefits package offered for eligible employees:

At least five years related experience is required.

We recognize our veterans by offering a company paid day off for Veterans Day