What are the responsibilities and job description for the HEALTH CARE COORDINATOR 1 position at State of Nevada (NV)?
Nevada Medicaid and the Nevada Health Authority is hiring for a Health Care Coordinator (HCC) 1 to underfill a Health Care Coordinator II in our Las Vegas District Office. You will auto progress to the HCC II when the minimum qualifications of the position are met. HCC’s evaluate individuals referred to the medical services program and provide care coordination services to Medicaid eligible clients; evaluate the need for medical services, treatment, equipment, and supplies and authorize payment; review programs and participate in program development. Health Care Coordinators in this position use multiple databases to research recipient data, eligibility information, and computer system interface issues. This position will assist walk-ins in the District Office lobbies to provide the recipient information regarding benefits and to troubleshoot complicated access to care issues.
Health Care Coordinators perform professional work related to program operations and auditing providers to ensure compliance with program policies and regulations. They evaluate individuals referred to the medical services program and provide ongoing case management services to Medicaid eligible clients; evaluate the need for medical services, treatment, equipment and supplies and authorize payment; screen individuals to determine appropriate level of care in nursing homes; review programs to ensure services are being provided in a cost effective manner; participate in program development by providing input on policies and procedures, forms, medical coverage and system enhancements. Licensure as a Social Worker or professional licensure or certification in a medical specialty applicable to the assignment.Assess potential client needs for case management services using assessment tools to identify social service and/or medical needs; develop and implement plans of care for those determined to be eligible for services; counsel and refer clients to services and/or contract with providers for services; maintain contact with clients through home visits and telephone calls; monitor the quality and cost of services provided to clients; periodically update plans of care; submit payment authorization requests; and maintain case files.
Participate in periodic reviews of facilities providing care to Medicaid eligible clients to validate and ensure adequacy of services and resident care; ensure reimbursement matches the cost of services provided; monitor nursing facility quality indicator reports; screen and assess Medicaid clients regarding discharge to community-based care; review medical records; document findings and deficiencies on appropriate forms; prepare reports of findings and participate in exit conferences; participate in independent professional reviews of providers to determine the quality of care, compliance with patient rights, and appropriateness of placement as assigned.
Review health care providers and fiscal agents to ensure clients are receiving appropriate services and payment is correct for services received; ensure providers and fiscal agents are in compliance with division policies and procedures; ensure employee health, certification and training needs are appropriate and properly documented in personnel records; verify client records have appropriate documentation and that authorized services correlate with services provided; confirm termination of services were appropriately documented and mandated reporting requirements were met; provide technical assistance regarding policies and procedures; complete written documentation using appropriate format; identify areas needing improvement and review plans of correction.
Process payment authorization requests from providers to ensure the requested service, treatment, equipment or supplies are medically necessary and in compliance with Medicaid criteria prior to approving or denying requests; review pertinent medical information and previous requests; evaluate medical necessity to justify payment by comparing the diagnosis and other medical information with the request; refer requests to a medical consultant for another medical opinion as necessary; render determinations in accordance with Medicaid policy and notify providers of decisions.
Review records from the fiscal agent, providers, clients and computer generated reports in order to identify abuse and potential fraud and to ensure claims were paid properly by the fiscal agent; refer financial errors to the fiscal agent for adjustment of charges and refer potential cases of fraud and abuse for further investigation.
Explain proper billing procedures to contract providers selected by the client; monitor the quality of care given by the provider to clients; and submit billings for services provided to the fiscal agent for payment.
Perform related duties as assigned.
Under direct supervision, incumbents become familiar with Medicaid policies and procedures and receive training in the range of duties described above. This is the entry level in the series and progression to the journey level may occur upon successful completion of the probationary period, meeting the minimum qualifications, and with the recommendation of the appointing authority.General knowledge of: theories, principles, practices, and methods of social work, nursing, or a health care field applicable to program assignment; dynamics of human behavior including interpersonal relationships and social interactions; client rights and confidentiality of information; case management practices; physical, psychological and social characteristics associated with human development.
Ability to: recognize basic medical and social needs; effectively interact with people of various social, cultural, economic, and educational backgrounds; communicate effectively both orally and in writing to obtain information, explain policies and procedures and persuade others to seek or accept needed services; analyze information, problems, and situations and reach logical conclusions; compose concise, logical, and grammatically correct correspondence, case narratives and reports; read and understand technical materials; assemble, analyze and report data; organize and prioritize work; work independently and as part of a team; operate a computer sufficient to enter, store and retrieve data.
Health Care Coordinators perform professional work related to program operations and auditing providers to ensure compliance with program policies and regulations. They evaluate individuals referred to the medical services program and provide ongoing case management services to Medicaid eligible clients; evaluate the need for medical services, treatment, equipment and supplies and authorize payment; screen individuals to determine appropriate level of care in nursing homes; review programs to ensure services are being provided in a cost effective manner; participate in program development by providing input on policies and procedures, forms, medical coverage and system enhancements. Licensure as a Social Worker or professional licensure or certification in a medical specialty applicable to the assignment.Assess potential client needs for case management services using assessment tools to identify social service and/or medical needs; develop and implement plans of care for those determined to be eligible for services; counsel and refer clients to services and/or contract with providers for services; maintain contact with clients through home visits and telephone calls; monitor the quality and cost of services provided to clients; periodically update plans of care; submit payment authorization requests; and maintain case files.
Participate in periodic reviews of facilities providing care to Medicaid eligible clients to validate and ensure adequacy of services and resident care; ensure reimbursement matches the cost of services provided; monitor nursing facility quality indicator reports; screen and assess Medicaid clients regarding discharge to community-based care; review medical records; document findings and deficiencies on appropriate forms; prepare reports of findings and participate in exit conferences; participate in independent professional reviews of providers to determine the quality of care, compliance with patient rights, and appropriateness of placement as assigned.
Review health care providers and fiscal agents to ensure clients are receiving appropriate services and payment is correct for services received; ensure providers and fiscal agents are in compliance with division policies and procedures; ensure employee health, certification and training needs are appropriate and properly documented in personnel records; verify client records have appropriate documentation and that authorized services correlate with services provided; confirm termination of services were appropriately documented and mandated reporting requirements were met; provide technical assistance regarding policies and procedures; complete written documentation using appropriate format; identify areas needing improvement and review plans of correction.
Process payment authorization requests from providers to ensure the requested service, treatment, equipment or supplies are medically necessary and in compliance with Medicaid criteria prior to approving or denying requests; review pertinent medical information and previous requests; evaluate medical necessity to justify payment by comparing the diagnosis and other medical information with the request; refer requests to a medical consultant for another medical opinion as necessary; render determinations in accordance with Medicaid policy and notify providers of decisions.
Review records from the fiscal agent, providers, clients and computer generated reports in order to identify abuse and potential fraud and to ensure claims were paid properly by the fiscal agent; refer financial errors to the fiscal agent for adjustment of charges and refer potential cases of fraud and abuse for further investigation.
Explain proper billing procedures to contract providers selected by the client; monitor the quality of care given by the provider to clients; and submit billings for services provided to the fiscal agent for payment.
Perform related duties as assigned.
Under direct supervision, incumbents become familiar with Medicaid policies and procedures and receive training in the range of duties described above. This is the entry level in the series and progression to the journey level may occur upon successful completion of the probationary period, meeting the minimum qualifications, and with the recommendation of the appointing authority.General knowledge of: theories, principles, practices, and methods of social work, nursing, or a health care field applicable to program assignment; dynamics of human behavior including interpersonal relationships and social interactions; client rights and confidentiality of information; case management practices; physical, psychological and social characteristics associated with human development.
Ability to: recognize basic medical and social needs; effectively interact with people of various social, cultural, economic, and educational backgrounds; communicate effectively both orally and in writing to obtain information, explain policies and procedures and persuade others to seek or accept needed services; analyze information, problems, and situations and reach logical conclusions; compose concise, logical, and grammatically correct correspondence, case narratives and reports; read and understand technical materials; assemble, analyze and report data; organize and prioritize work; work independently and as part of a team; operate a computer sufficient to enter, store and retrieve data.
Recruiter Contact Information: Jenn Trachet - jtrachet@admin.nv.gov
Salary : $59,508 - $87,821