This position is for Care1st Health Plan, a WellCare Healthplans, Inc. company.
Performs case processing, clinical evaluation and reconsiderations from receipt to adjudication. Utilizes clinical knowledge to evaluate and assess the clinical necessity of cases. Assists management in the implementation of process improvement, data reporting and adherence to departmental goals specific and regulatory requirements. Assists management in the day to day operational activities of the Retrospective Review group. Acts as a Subject Matter Expert with escalated calls, performs additional research for Medical Directors and creates/reviews metric reports regarding productivity and compliance.
Department: Health Services -Medicaid
Reports to: Clinical Care Manager
Location: E. Camelback Rd, Phoenix AZ 85016
Job Type: Hourly/ Non-exempt
- Assists management in the day to day operational activities of the Retrospective Review group.
- Monitors and recommends productivity and process enhancements to management.
- Ensures quality monitors are met on a consistent basis and works with management and the team to anticipate and account for changes in the quality model as they occur.
- Monitors and reviews department compliance relative to established metrics. Communicates and recommends changes to ensure compliance.
- Produces on a daily, weekly and monthly basis, data reports as directed by management and disseminates to the appropriate associates or management team.
- Takes a lead role in the resolution of process issues, medical director inquiries and specially directed projects as defined by the management team.
- Works with and ensure equitable distribution of reviews to the Medical Directors, facilitates requests by the medical directors and directs inappropriate referral issues to the appropriate market rep.
- Extensively uses and maintains database integrity and queries databases to provide accurate, relevant and useful information to the management team and associates.
- Reviews medical records and recommends a case disposition.
- Applies expert clinical knowledge in the assessment, evaluation and interpretation of clinical notes submitted by the provider.
- Evaluates the medical record so that patient age, time of day, severity of injury, availability of medical resources, etc. are considered when adjudicating the case.
- Specifically details in an electronic database the clinical aspects of the case and the reasoning for the determination outcome.
- When appropriate, seeks additional clinical advice and recommendations to properly adjudicate case.
- Serves in all phases of the reconsideration process from preloading of cases, case disposition and letter generation. Prepares cases for scanning and archiving.
- Verifies eligibility, timeliness and record completeness of cases and follows up with the provider as necessary.
- Electronically enters claim detail information in organization applications including Sidewinder and documents receipt, disposition and other noteworthy aspects of the cases in the application.
- Assists in resolving provider issues through the use of organizational databases and reports, communication with internal departments such as Claims and Appeals and contact/communication with clinical coordinators and Medical Directors.
- Participates in process development and testing of new process implementation.
- Evaluates data input and output for accuracy and ensures compliance with data integrity and corporate compliance directives.
- Participates in ad hoc projects that require clinical evaluation of medical records as directed by the Manager and/or Director.
- Identifies misuse and utilization of resources and communicates with Manager/Director/Medical Director as needed.
- Ensures timely processing and review of reconsiderations to meet departmental goals and state specific benchmarks for timeliness.
Education: Licensed Practical Nurse
- 5 years managed care experience with applied clinical responsibilities
- Medical coding or claims experience highly preferred
- LPN licensed in applicable state.
Special Skills (e.g. 2nd language):
Ability to review and interpret treatment plans. Ability to define problems, collect and interpret data, establish facts, draw valid conclusions and process work to completion. Knowledge of medical terminology and/or experience with CPT and ICD-9 coding.
Knowledge of electronic billing systems. Proficient in Microsoft Outlook applications, including Word, Excel, Power Point and Outlook. Ability to use proprietary health care management system