Central Intake & Managed Care Authorization Specialist

Central Intake & Managed Care Authorization Specialist
Senior Living Properties - Bedford, TX

Centralized Intake & Managed Care Specialist

SLP Operations, LLC operates 43 skilled nursing facilities in Texas and Oklahoma. SLP Operations, LLC is seeking a Centralized Managed Care Authorization Specialist to join its organization. Under the supervision of the Corporate Centralized Intake and Authorization Manager, duties and responsibilities of the Centralized Managed Care Authorization Specialist will include:

• Responsible for reviewing and fully approving potential admissions clinically and financially
• Review clinicals for skilled criteria, medical necessity, and communicating patient’s payor source to center along with supporting documentation
• Work with centers to verify benefits and secure authorizations for managed care services for the SLP portfolio of centers
• Serve as a key member of managed care, sales, and billing teams
• Communicate with regional and center personnel to obtain patient record and insurance information needed to secure authorizations
• Advocate for individual patient’s health care needs when requesting authorizations from MCOs
• Understand the importance of fostering referral source relationships, provider relationships, MCO relationships & center relationships
• Maintain referral, admission, and discharge documentation for case management and authorization purposes
• Be responsible for timely review, approval & communication of determination of potential admissions clinically and financially to our skilled rehabilitation and nursing centers.
• Efficiently and effectively, work with ADPS who manages all referrals
• Apply your clinical knowledge derived from education and experience as foundation for gathering appropriate clinical data to ensure appropriate placement, transfer facilitation, communication, and accurate documentation
• Participates in off hour and weekend on call duty as assigned

Job Type: Full-time

Department: Sales and Marketing

Reports to: Central Intake and Authorizations Manager

The ideal candidates are required to:

• Current unencumbered RN or LVN license
• Experience in a Skilled Nursing Setting: 1 year
• Must have CCM/ MDS experience
• Strong clinical reviews skills
•      Possess a current and working knowledge/understanding of MCO payor systems including- HMO, PPO, POS, EPO, Medicare, Medicaid, Worker’s Compensation
• Ability to work with little supervision
• Strong problem solving and critical thinking skills
• Excellent communication skills to include written, verbal and the ability to read, as well as follow oral and written direction at a level necessary to accomplish the job
• Demonstration of proficiency in computer skills, Microsoft Office, and Outlook with ability to learn new applications

Preferred qualifications:

•      Knowledge of and understanding of single case agreements and letters of agreement

•      Understanding of reading and comprehending MCO contract requirements and obligations

•      Experience with obtaining prior authorization for inpatient skilled admissions

OTHER JOB FUNCTION:

•     Ability to assign the appropriate ICD-10-CM code to identify the reason for skilled service authorization

•     Provides training and support to centers and regional staff related to maximizing authorization opportunities and continued authorization.
•     Knowing bed availability in centers that you cover
•     Continue to manage timely managed care/insurance authorizations.
•     Communicate with Administrators, DON’s, and BOM’s regarding patient care issues, needs, and concerns and advise when appropriate.
•      Work collaboratively with centers to manage all internal and external patient movements and the allocation of bed assignment
•      Communicate with Administrator and DON if placement of a specific patient will be problematic. Use problem-solving skills to determine the best course of action, which will be            satisfactory to the patient, the DON, and the center.
•     Be responsible for documenting and tracking all referrals, admissions, hospital transfers and transports.
• Assist in data collection, monitoring, evaluation, and analyzing of problems for the purpose of developing and implementing protocols, policies, and procedures.
• Follow specific protocols, policies, procedures, and utilize established resources.
• Quickly respond to all referrals with the aid of an electronic database of service profiles, approved clinical protocols and healthcare information.
• Obtains appropriate clinical documentation to support services and/or reimbursement level and financial documentation to support qualified payor source.
• Ensure accurate information from physicians, patients, and referral sources regarding the expected discharge plan is communicated.
• Responds to calls and/or inquiries regarding potential admissions and responds to these calls within 15 minutes if at all possible.  Document approval or denial on third party referral websites – Allscripts, CarePort, etc.
• Communicates information to ADPS and center sales/admissions teams, Administrator or Director of Nursing and Business Office Manager, when applicable and helps coordinates patient’s smooth transition into the center.
• Assists potential patients in selecting post-acute placement to Senior Living Properties centers.
• Develop and maintain relationships with referral sources; cooperate and collaborate with referral sources and colleagues.
• Provides VP of Sales & Marketing, COO, Regional Sales Managers, VPOs, RDOs, Regional teams and Center teams with information and feedback from the providers in the region.
• Adheres to established HIPAA confidentiality standards of patient/resident and client location information.
• Assists with generating additional referrals from hospital social services and discharge planning departments, physicians, case managers, insurance companies and new referral sources.
• Demonstrates growth in hospital referrals, as reflected in an increase of overall occupancy and quality mix in SLP centers.
• Read and familiarize self with State and Federal Nursing Facility regulations.
• Read and familiarize self with Nursing Facility 5-Star program along with Center ratings and understand how to respond to referral sources/ family members/ potential patients about ratings.
• Stay current and familiarize self with current healthcare and community trends including but not limited to Alternative Payment Models and changes in accounts, competitors, or healthcare community.
• Exhibit excellent customer relationship skills including telephone and personal contact with all of the call center’s customer groups, i.e., physicians and their office staffs, nurses, vendors and fellow employees, etc.
• Establish and maintains a high degree of awareness and knowledge of SLP’s medical staff, services and special programs.
• Maintain composure and customer-centric communication with challenging callers.
• Participates in off hour and weekend on call duty as assigned.

Benefits

We offer an Annual Incentive plan, as well as a wide array of benefits including medical, dental, vision, employer-paid life/AD&D, supplemental critical illness/accident/cancer/disability, paid time off and paid holidays!

Providing love and attention, one resident at a time…

We are an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.

PHYSICAL AND SENSORY REQUIREMENTS (with or without the aide of mechanical devices):

• Walking, reaching, bending, grasping, pushing, and pulling, ability to communicate with personnel, ability to read and write, ability to understand and follow written and oral instructions and directions, ability to instruct other staff and ability to travel.

• Health Insurance Portability and Accountability Act (HIPAA):
• The Health Insurance Portability and Accountability Act (HIPAA), signed into federal law in 1996, set national standards regarding security and privacy of a person’s health information.

• Our Facility is committed to protecting the privacy, security and integrity of individually identifiable health information received from or on behalf of our employees.  The Facility adheres to the highest standards of integrity in the performance of its business and is prepared to maintain compliance with HIPAA and other regulatory requirements by adopting and adjusting policies and processes as necessary.  All employees are required to adhere to all HIPAA regulations.
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• JOB DESCRIPTION REVIEW:
• I understand this job description and its requirements; and that I am expected to complete all duties as assigned.  I understand the job functions may be altered from time to time.

• I have noted below any accommodations that are required to enable me to perform these duties.  I have also noted below any job responsibilities or functions that I am unable to perform, with or without accommodation.
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• ______________________________________________________________                    _________________________
• Associate’s Signature                                                                                                                         Date
• ______________________________________________________________                    _________________________
• Supervisor/Orientation Leader                                                                                                Date
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• Cc:   Personnel File/Individual Associate                                                                                                Date: