Hours

Shift Start Time:

8:30 AM

Shift End Time:

5 PM

Additional Shift Information:

Weekend Requirements:

Not Specified

On-Call Required:

No

Hourly Pay Range (Minimum - Midpoint - Maximum):

$26.500 - $33.125 - $39.750

The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

What You Will Do
To review complex requests for medical care and services, including requests for outpatient care, elective inpatient admission, skilled nursing facility admission, retrospective claim review, medical equipment, and home health in accordance with Sharp Rees-Stealy Medical Group (SRS) referral guidelines. Provide support and facilitation of care coordination services provided by the Case Managers (Levels I-IV) to members.
Required Qualifications

• Other : successful completion of ICD-9 and CPT coding classes, or equivalent work experience.
• 3 Years working in the managed health care field, preferably HMO or delegated risk medical group/IPA setting.
• 1 Year experience with medical coding and data entry, preferably in a managed care environment.

Preferred Qualifications

• Other : successful completion of Medical Assistant Program or equivalent.

Essential Functions

• Assess the need for health care resources and insurance
  Obtain detailed benefit coverage for the more complex requests for service specific to member plan coverage.
  Apply the principles of SRS guidelines and Health Plan benefit guidelines to approve referrals designated at the CC level.
  Check eligibility status.
  Investigate and follow-up on all eligibility issues in accordance with health plan and SRS guidelines.
• Process referrals for prior authorization
  Coordinate, review and process the more complex referrals for prior authorization for medical care and services, including emergency room, urgent care visits, inpatient admission, outpatient care, durable medical equipment, home care and other miscellaneous services for the efficient and effective delivery of patient services.
  Perform reviews of the more complex prior authorization referrals.
  Obtain necessary medical information by following the SRS PAI process.
  Identify and refer requests for review by higher level staff (CM and above) within department turn around time (TAT) standards.
  Research and assist in the denial process; gather documentation after review by the Medical Director, ensure packet is complete, assess and select the appropriate denial reason, and maintain mandated TAT for denials.
  In addition, the Care Specialist - SRS will perform the following functions: obtain and gather clinical information from multiple sources including use of Sharp applications to retrieve patient medical records for review by Case Managers; maintain and organize data, prepare and distribute reports within designated timeframe; manage correspondence to members and PCP, health plans and other service providers; make phone calls to members, physician offices, health plans, and providers to assist in care coordination under the guidance of case managers; organize and maintain case files; provide clerical support and assistance to the Case Management team; contribute to the continuous improvement initiatives of the Case Management team to deliver quality and timely interventions; maintain data and run reports in an organized and timely manner; and organize and implement daily work plan for chronic disease activity schedule under the guidance of chronic care managers.
• Retrospective claims process
  Coordinate, review and process more complex retrospective claims for medical care and services, including emergency room, urgent care visits, inpatient admission, outpatient care, medical transportation, durable medical equipment and other miscellaneous services for the efficient and effective facilitation of claim adjudication.
  Research and interpret all ICD-9, CPT and HCPC coding using appropriate tools.
  Make determinations on the more complex claims that are designated CC authorization level within SRS TAT guidelines.
  Identify and refer claims for review by higher level staff (CM and above) within department standards.
• Typing skills
  Using a keyboard, required to type proficiently and accurately.
  Ability to type a minimum of 30 words per minute with 0-2 errors.
  Ability to proof work.

Knowledge, Skills, and Abilities

• Excellent organizational and time management skills including the ability to multitask.
• Excellent analytical and problem solving skills.
• Proficient in medical terminology and current standards of clinical practice.
• Proficient in use of ICD-9, CPT4 and HCPC coding systems.
• Proficient in typing and computer data entry (45 wpm).
• Excellent verbal and written communication skills.
• Ability to read, speak and hear English clearly.
• Ability to work independently in research and decision making with minimal direction from higher level staff.
• Occasional travel between Sharp HealthCare facilities and provider offices; must provide own transportation.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class