1. Understand, promote and review with the principles of medical management to facilitate the right care at the right time in the right setting.
2. Communicate effectively and interact with providers, staff and health plans daily or as indicated regarding medical management and referral authorization issues.
3. Maintain a working relationship with PACM colleagues, the pre-auth coordinator team, high-risk nurse case managers, inpatient nurse case managers, medical directors, and network management.
4. Research alternative care plans and when necessary, assist in the routing of members to the most appropriate care/setting, in order to provide right care/right setting.
5. When necessary, act as liaison between the case managers, UM coordinators, contracted providers (PCPs/specialists/ancillary), and the members/families.
6. Perform case reviews base on key screening outpatient indicators, and evaluate the PCP submitted plan of care for its completeness of documentation, consistency of treatment with medical groups clinical practice guidelines, adherence to standard evidence-based or consensus guidelines, and health plan and CMS guidelines and/or medical policies.
7. Maintain regulatory Turnaround Time Standards per regulatory guidelines.
8. Document accurately and completely all necessary information in authorization notes.
9. Approve those approvable requests as indicated based on protocols.
10. Forward those authorization requests needing physician review with an accurate summary of the case, and recommendation.
11. Understand all applicable capitation contracts and how they apply to review duties.
12. For those PACMs involved in DME, understand the contracts, and need to review rental vs. purchase approvals, and continued use so that equipment is picked up when needed.
13. When appropriate, coordinate and review for medical necessity and appropriate utilization any ancillary professional services, i.e. (home health, infusion, PT, OT, ST, etc.).
14. Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner.
15. Participates in “service recovery” through follow-up with an upset patient or provider, gathering information, and demonstrating empathy.
16. Identifies network needs and report to management for potential contracting opportunities.
17. Other duties as assigned
Source: Indeed.com
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