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Referral Management Assistant Emergency Care Management - Fair Oaks Medical Center
•30 days ago
| Hours | Full-time, Part-time |
|---|---|
| Location | fairfax, Virginia |
About this job
Under the direction of a licensed provider, performs administrative functions to promotes coordination of care to different acute levels of care w/in the healthcare delivery system & coordinate emergency care w/in the scope of defined authority.
Essential Functions:
* Facilitates care of members in under the direction of Kaiser Permanente of the Mid-Atlantic States (KPMAS) staff, Mid-Atlantic Permanente Medical Group (MAPMG), Network, contracted & noncontracted providers.
* Is the first & essential point of contact to receive & processes emergency & urgent care notification regarding Kaiser Permanente members in coordination w/ MAPMG.
* Provides technical & administrative support in a professional manner for KPMAS & Hospital Services Management (HSM), Inpatient Behavioral Health offices, & Critical Decision Units (CDUs).
* Coordinates health care services for members in affiliated & non-affiliated service delivery systems.
* Conducts concurrent review of ER patients & make follow-up appointments as indicated; reserve beds as requested &, arranges ambulance transportation w/ attention to supporting therapies per guidelines.
* Assists w/ core & non-core facility repatriations to ensure timely, quality care of members & admissions in accordance w/ policy & procedures.
* Processes inpatient admission authorizations, short stay & ER referrals per policy & procedures.
* Processes emergency requests for Oxygen & biliblankets after normal UMOC business hours.
* Maintains knowledge KPMAS contractual relationships to coordinate emergent & urgent care in the most appropriate setting.
* Maintains & applies knowledge of benefits eligibility & Explanation of Coverage Language (EOC).
* Initiates administrative denials as appropriate, including verbal notification to members &/or facilities of denial decisions, grievance/appeals rights & processes.
* Follows local, state & federal jurisdictional regulations on applicable activities & projects to ensure regulatory compliance.
* Ensures collaborative working relationships w/ various professional providers & others to determine availability of services to be rendered.
* Determines applicability of coordination of benefits for Medicare, Workers' Compensation, & third party liability.
* Provides continuous telephone coverage for the Utilization Management Operation Center.
* Orients & trains internal & external providers & staff regarding department functions & interdepartmental relationships.
* Maintains referral process workflow.
* Functions as a member of the Emergency Case Management (ECM) Team to assist in a variety of functions.
* Meets or exceeds customer service standards: call handle times/volumes, referral processing accuracy & productivity.
* Manages ECM referral work queue & workflows.
* Compiles daily & monthly statistical reports.
* Performs other related duties as directed.
Basic Qualifications:
Experience
* Minimum two (2) years of experience in health care or health insurance required.
Education
* High School Diploma or General Education Development (GED) required.
License, Certification, Registration
* N/A
Additional Requirements:
* Knowledge of Medical Terminology, ART Certification, UB92, HCFA, Medicare Billing Guidelines, Coordination of Benefits, Medical Billing Practices and, Inpatient and Outpatient Coding.
* Proficiency in the use of applicable computer software.
Preferred Qualifications:
* N/A
Essential Functions:
* Facilitates care of members in under the direction of Kaiser Permanente of the Mid-Atlantic States (KPMAS) staff, Mid-Atlantic Permanente Medical Group (MAPMG), Network, contracted & noncontracted providers.
* Is the first & essential point of contact to receive & processes emergency & urgent care notification regarding Kaiser Permanente members in coordination w/ MAPMG.
* Provides technical & administrative support in a professional manner for KPMAS & Hospital Services Management (HSM), Inpatient Behavioral Health offices, & Critical Decision Units (CDUs).
* Coordinates health care services for members in affiliated & non-affiliated service delivery systems.
* Conducts concurrent review of ER patients & make follow-up appointments as indicated; reserve beds as requested &, arranges ambulance transportation w/ attention to supporting therapies per guidelines.
* Assists w/ core & non-core facility repatriations to ensure timely, quality care of members & admissions in accordance w/ policy & procedures.
* Processes inpatient admission authorizations, short stay & ER referrals per policy & procedures.
* Processes emergency requests for Oxygen & biliblankets after normal UMOC business hours.
* Maintains knowledge KPMAS contractual relationships to coordinate emergent & urgent care in the most appropriate setting.
* Maintains & applies knowledge of benefits eligibility & Explanation of Coverage Language (EOC).
* Initiates administrative denials as appropriate, including verbal notification to members &/or facilities of denial decisions, grievance/appeals rights & processes.
* Follows local, state & federal jurisdictional regulations on applicable activities & projects to ensure regulatory compliance.
* Ensures collaborative working relationships w/ various professional providers & others to determine availability of services to be rendered.
* Determines applicability of coordination of benefits for Medicare, Workers' Compensation, & third party liability.
* Provides continuous telephone coverage for the Utilization Management Operation Center.
* Orients & trains internal & external providers & staff regarding department functions & interdepartmental relationships.
* Maintains referral process workflow.
* Functions as a member of the Emergency Case Management (ECM) Team to assist in a variety of functions.
* Meets or exceeds customer service standards: call handle times/volumes, referral processing accuracy & productivity.
* Manages ECM referral work queue & workflows.
* Compiles daily & monthly statistical reports.
* Performs other related duties as directed.
Basic Qualifications:
Experience
* Minimum two (2) years of experience in health care or health insurance required.
Education
* High School Diploma or General Education Development (GED) required.
License, Certification, Registration
* N/A
Additional Requirements:
* Knowledge of Medical Terminology, ART Certification, UB92, HCFA, Medicare Billing Guidelines, Coordination of Benefits, Medical Billing Practices and, Inpatient and Outpatient Coding.
* Proficiency in the use of applicable computer software.
Preferred Qualifications:
* N/A
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