Care Coordination Specialist

Kaweah Health is a publicly owned, community healthcare organization that provides comprehensive health services to the greater Visalia area in central California. With more than 5,000 employees, Kaweah Health provides state-of-the-art medicine and high-quality preventive services in our acute care hospital, specialized health centers and clinics. Our eight-campus healthcare district has 613 beds and offers comprehensive health services across a broad continuum of care. It takes a special person to work for Kaweah Health. We serve a region where the needs are great, which makes the rewards even greater. Every day, we care for people facing unique challenges and in need of healing. Throughout it all, our focus is to make a difference, and we do - in the health of our patients, our loved ones, and our community. Benefits Eligible Full-Time Benefit Eligible Work Shift Day - 8 Hour or less Shift (United States of America) Department 7290 Home Health Agency The Care Coordination Specialist works in collaboration with RN Case Management (CM) staff to gather clinical data to monitor quality and effectiveness of patient care. Acts as a liaison between RN CM and insurance companies by transmitting clinical data for review. Assists with planning and execution of safe discharge plan in a timely manner while working in collaboration with the multi-disciplinary team. QUALIFICATIONS Education Required: Two years of college or equivalent training/experience in health-related field Experience Required: Utilization review and/or coding experience Knowledge/Skills/Abilities Must understand basic medical terminology. Strong organizational and multitasking skills, with the ability to manage multiple patients and tasks simultaneously. Excellent communication and interpersonal skills, with the ability to interact effectively with patients, families, and healthcare professionals. Knowledge of discharge medication delivery processes and procedures, including coordination with the outpatient pharmacy and the patient and or family. Ability to work collaboratively with interdisciplinary team members and healthcare professionals. Strong computer skills, with proficiency in electronic medical record documentation preferred. Proficient in using Excel for documentation. JOB RESPONSIBILITIES Essential Reviews and records utilization review data for assigned caseload in a manner to ensure all inpatient records are current. Refers to Case Management team any variances that relate to concurrent review of the medical record. During chart review, is aware of criteria for quality variances. Complies with Kaweah Health Policy by reporting utilization variances to Case Management Committee and/or the P.I. department as indicated. Reviews medical records for admission and continued stay utilizing InterQual Severity of Illness and Intensity of Services for appropriateness of the admission and continued stay. Must also review all cases transferred in and out of special/intensive care areas using specific criteria. Participants in Sub Committee reviews as designated. Informs the Case Management Team and attending physician of any questionable or denied cases resulting from the review of the onsite Medi-Cal reviewer, CMRI or private insurance companies. Initiates further action by following guidelines set forth in the Hospital Case Management Plan. Facilitates and coordinates placement of patients in appropriate long-term care facilities. Facilitates arrangements for acute transfer to other acute facilities when indicated. Assists case management team with discharge planning services that can include coordination of equipment, home care, home health, and transportation services. Participates in Continuum of Care rounds. Accumulates information on community resources and links patients, families and staff to appropriate services. Answers the telephone, screens calls and takes messages as appropriate, per hospital protocol. Addendum (essential for specific dept) INSURANCE SPECIALIST: Responsible for all clerical aspects of utilization review including, but not limited to, processing of referrals, input of authorizations into the system, mailing of referrals and attendance at Case Management meetings. Maintains & manages all health plan benefit databases in the system and updates as needed. Transmission of insurance reviews (Initial & Concurrent). Takes telephone requests for authorizations. Completes retro reviews in a timely manner. Documents authorizations in SoftMed and Invision. Completes CCS and other referrals as indicated with appropriate documentation. Communicates payer needs to Case Managers in a timely manner. Generates reports that summarize referrals and authorization activity. Coordinates the denial appeal process in conjunction with management/RN supervision, including but not limited to writing and/or calling appeals to private insurers and Medi-cal. Coordinates the input of registrar data and provides assistance to the RN Adm #J-18808-Ljbffr