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
Outpatient Coder Certificate within 6 months of hire OR Certified Coding Specialist within 6 months of hire OR Professional Coder Certificate 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.).
Preferred Qualifications:
Clinical background preferred.
Medical Terminology Certification preferred.
Bachelors degree.
COMPANY: KAISERTITLE: Coordinator, Continuum CareLOCATION: Decatur, GeorgiaREQNUMBER: 1254782External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.
Full-time