Bilingual Associate Clinical Administrative Coordinator - Miami, FL

Position Description:

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Our Customer
Service teams have a serious responsibility to make every contact informative,
productive, positive, and memorable for what it says about how much we care.

Employees in this position include those responsible for
Administrative Intake of members or managing the Admission/discharge
information post-notification, and working with hospitals and the Clinical
team. Function includes managing Incoming calls, managing requests for services
from Providers/members, providing information on available Network services and
transferring members as appropriate to Clinical staff. Also manages the
Referrals process, processes Incoming and Outgoing Referrals, and Prior Authorizations.

Primary Responsibilities:

• Under the general direction of the
  Clinical Director or designee, provide Authorizations for Hospital
  Admissions, Skilled Nursing facilities, Rehabilitation facilities,
  Specialist Providers, Outpatient services and Ancillary services such as
  Home Health Care, Durable Medical equipment, Orthotics/ Prosthetic
  devices, Colostomy supplies and Infusion services, and others as
  directed.
  
• Assist in the coordination of
  Discharge Planning activities on all Plan participants. The Plan is
  dependent upon participants' Discharge needs.
  
• Communicate with a variety of Clinical disciplines to clarify and enforce Plan policies and procedures.
  
• Collect and review of service requests for completeness and referral to Clinical Director or Medical Director.
  
• Answer the telephone ACD line, as scheduled.
  
• Verify benefits in Diamond System.
  
• Referral filling and distribution to the designee coordinator.
  
• Referral processing for
  Outpatient services, including but not limited to Outpatient Surgeries,
  Rehabilitation Therapies, Radiation Therapy, Chemotherapy, Provider's
  evaluations and Follow-up, Ancillary services, such as DME's, HHC and
  Orthotics/Prosthetic devices.
  
• Collection of data for Clinical oversight.
  
• Pre-Authorization entering for
  Requests of services such as Clinical Evaluations/Follow-up visits,
  Outpatient procedures, Inpatient services such as: Elective Admissions,
  Emergency Room Admissions, Skilled Nursing facilities, Rehabilitation
  facilities, Outpatient services, Ancillary services, such as DME's, HHC
  and Orthotics/ Prosthetic Devices in Diamond System, when applicable.
  
• Daily notification to PCP'S of
  Admissions Authorizations to Acute facilities. Authorization entering
  for Plan Members under the care of Dialysis and Hospice services.
  
• Process Denial Authorizations
  for non-coverage services for Medicare and Medicaid plan participant's
  adherence to timeliness for
  determinations.                                            
  
• Maintain and update daily
  reports as required, including but not limited to: Daily Hospital
  Admission Census, Skilled Nursing Facility Census, Rehabilitation
  Census, Part B Census, and Home Health Care Census.
  
• Maintain monthly reports for
  Dialysis, Hospice, Healthy Start, Medicaid Sterilization, Abortion and
  Hysterectomy, Re-admission to Acute facilities, Admissions to Acute
  facility and Telephone ACD Reports.
  
• Assist Case Managers and PCPs
  in the coordination of Discharge planning from Acute Facilities to
  Sub-Acute placements and from Skilled Nursing facilities and
  Rehabilitation facilities to Home and to Community services.
  
• Maintain record of Discharge planning implemented and coordinated services.
  
• Send Discharge Notification form with all discharge planning arrangements to PCPs upon discharge from facilities.
  
• Follow up with patient to assure accuracy that the coordination of services such as HHC and DMEs has been completed.
  
• Consult with various Clinical disciplines regarding specifics patient and their follow-up needs.
  
• Identify Risk Management issues thru Health Plan guidelines and requirements and submit Incident Reports to Director.   
  
• Participate in monthly staff meetings.
  
• Participate in scheduled In-service for different disciplines.
  
• Perform Health Risk Assessment program.
  
• Ensure compliance with Risk Management policies and incident reporting.
  
• Assist with Health Risk Assessment data verification.