Department :

10429 Home Office WI - Insurance Verification

Status : Full time

Full time

Benefits Eligible : Hou rs Per Week :

Hou rs Per Week :

Schedule Details / Additional Information :

Monday Through Friday 9Am - 530PM

Remote Role

Must be willing to obtain IL RN license within 6 months after hire.

Case Manager Insurance and Billing Background Preferred

Major Responsibilities :

• Function as a clinical liaison to internal and external managed care customers.
• Partner with external case managers to transition patients to appropriate levels of care.
• Monitors variances in service utilization and implements improvement processes with staff.
• Monitors service utilization, cost, and rehospitalization.
• Collaborate with the education department, identifies areas for staff development and education related to managed care.
• Assess capitated members / patients for home care (as appropriate) including benefit / eligibility verification, medical necessity and appropriateness of referral.

Recommends alternative cost-effective solutions where appropriate.

• Review clinical documentation for managed care payer audits prior to submission to ensure medical necessity has been met in accordance to managed care payer and or state / federal regulations.
• Assures that care / service is provided to meet desired clinical outcomes and in accordance with contractual arrangements, state / federal regulation, accreditation and professional standards.
• Provides and documents accurate and timely assessment and dates to external case mangers regarding all home care services as required by payer contracts and on an ongoing bases (non capitated patients).
• Participate in multi-disciplinary patient care conferences. Provide direction for care provision to facilitate communication and coordination of services, and to promote outcome driven, cost effective care.
• Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served.

Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his / her age-specific needs, and to provide the care needed as described in the department's policies and procedures.

Age-specific information is developed further in the departmental job standards.

Licensure, Registration, and / or Certification Required :

Registered Nurse license issued by the state in which the team member practices.

Education Required :

Bachelor's Degree (or equivalent knowledge) in Nursing.

Experience Required :

Typically requires 3 years of experience in home care clinical experience preferred or 2 years experience as a case manager with insurance company.

Knowledge, Skills & Abilities Required :

• Must have excellent communication skills.
• Must have excellent time management skills.
• Knowledge of home care regulations.
• Must have excellent organizational skills.
• Must have basic knowledge of Microsoft office products ie : Word, Outlook, Excel.

Physical Requirements and Working Conditions :

• Exposed to normal office environment.

Last updated : 2024-05-23