Case Management Specialist, Population Health bei Mercyhealth

Job Duties: 

• Oversees administrative processes and projects for case management department, including insurance authorization submission and facility referral management.   

• Develops reporting to monitor key performance indicators and performance improvement initiatives in utilization management, such as length of stay, pre-service denials management, and department productivity. Collaborates with application analysts and report consumers to understand and identify advanced reporting needs. Creates design specifications for new reports. Develops reports according to available specifications for utilization management. Validates and keeps reports up to date by monitoring specifications. Generates and distributes reports. Acts as a resource to leaders throughout the system in acquiring and interpreting data and reports. Utilizes third party data visualization and informatics tools including but not limited to Power BI and IL COMPdata.  

• Assists case management team with arranging appropriate follow-up appointments/procedures for patients, delivery of Medicare notices/letters, completion of Advanced Directives and completion of PASRRs.   

• Functions as primary contact for insurance authorizations and regulatory agency inquiries. Provides information to patient financial department, insurance verifiers, and medical records regarding payment issues and clinical oversight. Routes clinical review requests to department staff to complete the authorization process. Monitors completion of insurance requests and authorization. Calls insurance companies, H S I, and CMS with patient status changes, discharge dates, and QIO appeal status.  

• Screens telephone calls and visitors to assist them in resolving complex customer service inquiries. Routes internal and external inquiries as needed to appropriate department staff for timely resolution. 

• Performs secretarial duties to support efficient operations of the department to include: use of computer as well as department specific software, timely and accurate typing, formatting of documents, retrieving and sorting mail, record keeping and filing, coordinates/schedules educational meetings for department staff, relays information in timely manner and utilizes appropriate tools for communication.  

ESSENTIAL DUTIES AND RESPONSIBILITIES   

• Oversees administrative processes and projects for case management department, including insurance authorization submission and facility referral management.   

• Develops reporting to monitor key performance indicators and performance improvement initiatives in utilization management, such as length of stay, pre-service denials management, and department productivity. Collaborates with application analysts and report consumers to understand and identify advanced reporting needs. Creates design specifications for new reports. Develops reports according to available specifications for utilization management. Validates and keeps reports up to date by monitoring specifications. Generates and distributes reports. Acts as a resource to leaders throughout the system in acquiring and interpreting data and reports. Utilizes third party data visualization and informatics tools including but not limited to Power BI and IL COMPdata.  

• Assists case management team with arranging appropriate follow-up appointments/procedures for patients, delivery of Medicare notices/letters, completion of Advanced Directives and completion of PASRRs.   

• Functions as primary contact for insurance authorizations and regulatory agency inquiries. Provides information to patient financial department, insurance verifiers, and medical records regarding payment issues and clinical oversight. Routes clinical review requests to department staff to complete the authorization process. Monitors completion of insurance requests and authorization. Calls insurance companies, H S I, and CMS with patient status changes, discharge dates, and QIO appeal status.  

• Screens telephone calls and visitors to assist them in resolving complex customer service inquiries. Routes internal and external inquiries as needed to appropriate department staff for timely resolution. 

• Performs secretarial duties to support efficient operations of the department to include: use of computer as well as department specific software, timely and accurate typing, formatting of documents, retrieving and sorting mail, record keeping and filing, coordinates/schedules educational meetings for department staff, relays information in timely manner and utilizes appropriate tools for communication.