Medical Management Coordinator
- Bronx, NY
PURPOSE OF THE POSITION:
The purpose of this position is to provide efficient and appropriate care management and customer service to Affinity Members and Providers through utilization review, response to Member and Provider inquiries, and phone and mail outreach in support of clinical initiatives. Responsibilities may include some or all of those summarized below and the
Medical Management Coordinator concentrates in either the Medical Management call center function, including triaging services and utilization review or the clinical outreach function. The Medical Management Coordinator supports all functions as required and to that purpose is cross-trained in functions that are not their area of concentration.
- Call Center and Utilization Review and Support
- Triages and directs appropriately all incoming requests for medical services such as elective and emergent admissions, outpatient procedures, out of network requests, durable medical equipment, specialty
visits, and diagnostic testing.
- Researches system for member eligibility. Creates and records authorization information in CCMS & E-Track phone log related to various service requests.
- Utilizes Corporate Medical policy and Medical Management policy to appropriately direct requests for Case Management or Medical Director Review.
- Manages standing referrals based on Department and Corporate Medical policy and procedures.
- Administers the department processes associated with the following services requiring documentation and review of clinical information: Physical Therapy, Occupational Therapy, Speech Therapy, Maternity, Cardiac Catheterization, and Transportation.
- Effectively communicates with the Customer Service, Enrollment, Provider Relations and Claims departments to resolve problems that require coordinated resolution, i.e., member eligibility, discrepancies involving coding or claims form versus authorization information.
- Coordinates Medical Management process with third party vendors supporting clinical services that may include mental health and substance abuse services, dental services and vision care.
- Educates Providers regarding Affinity Health Plan Medical Management and referral policies and procedures.
- Responds to voice mail messages received by the Medical Management Department, logging the calls, calling Provider for any additional information necessary to the creation of an authorization, to update them regarding member eligibility, and to provide them with the authorization number as indicated. Triages calls from Providers requesting services for pharmacy overrides, ensuring processing of prior authorization form by Provider.
- Sorts and processes HRA Assessment forms and documents in CCMS, identifying members with Asthma, Pregnancy, Mental Health or Substance abuse issues, or other Health issues for outreach.
- Facilitates transportation requests for ambulette services according to benefit contract and medical necessity.
- Clinical Outreach
- Provides supportive care management services for patients discharged from inpatient admissions with selected diagnoses, including confirmation of follow-up plans, appointment assistance and interaction with primary care sites and providers to ensure continuity of care.
- Conducts outreach at identification of pregnancies and again at delivery to promote timely and comprehensive prenatal and postpartum care, initial newborn care and ongoing pediatric care, including immunizations.
- Provides supportive care management services for Members with health risk factors or health care needs as identified by Affinity and/or the Medicaid Enrollment Broker's Health Risk Assessment, including 1) identification of specified at-risk populations with referral to appropriate case manager 2) telephonic and/or mailed education, 3) assistance with appointments and 4) direction/redirection of members to in-network providers.
- Identifies Members whose health risk factors, clinical status, and/or personal circumstances require further assessment intervention; refers individual psycho-social or provider service issues that are unable to be resolved to appropriate staff.
- Creates and maintains designated computer-based and/or paper files of clinical outreach activities; prepare daily summaries of task status and activities.
- Reviews, selects and/or assists in development of promotional health education materials on various topics targeted for activities and/or distribution to Members/community; generates mailings for various clinical outreach initiatives implemented as part of Plan-wide performance improvement plans.
- Assists in organizing community education programs and conducting community education activities on selected topics (e.g. Health Fairs, health education classes, etc.)
- Provides outreach/ data collection/ reporting support to Case Managers in relation to Disease Management and Case Management initiatives.
- Assists with the daily retrieval, sorting & distribution of all incoming faxes, and outbound faxing as required.
- Performs other duties and responsibilities as necessary or assigned.
- High School Diploma or equivalent knowledge required; Associates Degree preferred
- Medical Assistant License or experienced with medical terminology required
- ICD-9 & CPT-4 Coding experience preferred.
- 2 years of related work experience, preferably in a health care environment.
- Proficient Computer skills, including Microsoft Office applications.
- Excellent oral and written communications skills.
- Special interpersonal skills as demonstrated by
- the ability to persuade and motivate Members to access appropriate medical resources.
- Ability to type a minimum of 35 wpm.
- Excellent customer service skills as demonstrated by courtesy, accuracy and follow-through.
- Ability to prioritize multiple tasks as demonstrated by the timely and successful completion of assigned tasks.
- Bilingual English/Spanish preferred.
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