Case Manager Admissions - full-time, Monday - Friday

Job Title:  Case Manager-Admissions                                                          
Job Location:  Lincoln      
Status:   Exempt      


JOB OVERVIEW

Responsible for completing clinical and financial assessments for referrals to Madonna Rehabilitation Hospitals for all payors that require authorization for admissions.  Ensures timely, efficient and cost-effective patient admissions to short-term rehabilitation programs. Coordinates with referral sources, payor sources and Manager of Admissions, for optimal program placement.  Contributes to establishing and maintaining strong positive working relationships with payors.  Communicates with inpatient teams, case managers and patient accounting to contribute to an efficient and coordinated program of care. Responsible for identifying cases that could be a potential â??financial riskâ? to Madonna Rehabilitation Hospital and Madonna Long Term Care Hospital at the time of referral/precert process. The key element to this role is an appreciation of the CAS (Customer Access System).  


ESSENTIAL FUNCTIONS
 

• Process payor authorization and denials, involving and communicating with Admissions Team for completion.
• Analyze pre-admission information and assess rehabilitation potential.
• Determines limitations of payor benefits, directing Admissions Team as needed prior to supporting admission (coordination of benefits, obtaining denials, OON process, P2P process.
• Provide department assistance and coverage as assigned.
• Serve as backup to submit appeals as needed.
• Develop and maintain networking relationships with appropriate associates to gain knowledge, share information regarding rehabilitation services (e.g., payors, discharge planners, external case managers) and promote problem resolution and customer satisfaction.
• Identify need for Director of Reimbursement to negotiate specific case agreements with commercial insurance companies, workers compensation companies to ensure optimal reimbursement.
• Coordinate with patient accounts to identify resolutions of non-payment or incorrect payments.
• Assist in identification of payor issues related to currently held contracts and share information with appropriate personnel. This may include identifying changes in network usage or identifying potential for establishing new contracts.
• Train new staff, as appropriate, in obtaining sufficient information when determining benefit eligibility and trends which may impact obtaining preadmission assessments, and in communication of trends which referral sources may find pertinent.
• Via High Risk Notification, communicate to all internal business sectors impacted by the risk.
• Follow instruction from supervisor to perform other functions as assigned in order to achieve the goals within the department.
• Maintain a clean, organized and safe environment.  Handles and operates all necessary equipment and performs required duties according to established safety standards to maintain compliance with regulations and prevent injury.
• Must be able to operate copier, telephone, fax machine and have proficient computer skills, including e-mail, word processing, presentation, and spreadsheet functions.
  
  QUALIFICATIONS 
  
• Active Nebraska Nursing license or Bachelorâ??s Degree professional in an allied health area (social work, occupational therapy, physical therapy, speech pathology, rehabilitation counseling, etc.)
• One year relevant work experience required.
• In-depth knowledge of clinical terminology and the ability to complete clinical assessments required.
• Requires extensive knowledge of insurance types (e.g., HMO, PPO, POS); insurance terminology (e.g., preferred provider network, coordination of benefits); insurance professionals (e.g., case managers, utilization review coordinators, medical reviewers, claims adjudicators, provider liaisons); and insurance payment provisions (e.g., per diems, discount off charges, case rates, carve outs).
• Also requires working knowledge of Medicare, Medicaid and Workers Compensation provisions and how these programs coordinate with commercial insurance coverage.