Overview
Required : Bilingual (Spanish)
Shift : 9-5:30pm and 10-6:30pm
Responsible for handling customer concerns through research and communication with involved departments/service level agreements and client products. Collaborates with internal and external partners and staff to achieve resolution of concerns. Manage database for cases. Responsible for timely case resolution and maintaining compliance. Exhibit a high level of case management expertise and demonstrated leadership skills. Utilize care coordination to address patient and physician concerns; obtain insurance approval for designated therapy and proactively plan to avoid the potential of delayed coverage by working with the patient, family, insurance, company, physicians, workplace, benefits administrators, and persons from other areas. Facilitate the case management process along the healthcare continuum. Assist with Benefit Investigations upon program need. Work directly with Program Supervisor to resolve escalations with the team. Own escalations from receipt to resolution. Assist with the training of new hires and refresher training needed individually or for the team as a whole. Collaborate with leadership on training materials and agendas. Identify program gaps within flows or processes and collaborate with leadership on best practices. Collaborate on process updates and assist through implementation, which can include assisting with document updating and control.
Responsibilities
- Manages the Care Coordination process within an assigned territory. Balances patient and physician needs with the business realities and necessities of the program. Establishes and maintains professional and effective relationships with all internal and external customers (i.e.: care coordination colleagues, care field team, patient advocacy groups, insurance company case managers, specialty pharmacies, physician office staff, and office coordinators)
- Assesses physicians’ needs and develops action plans that proactively mitigate delays in therapy. Coordinates the exchange of all patient-related information with internal and external customers (i.e.: patients, families, healthcare providers, insurance companies, and specialty pharmacies). Effectively manages database including data on each individual, their insurance, coverage approvals, ongoing coverage requirements, and all patient and provider interactions
- Keep up to date with reimbursement process, billing/coding nuances, insurance plans, payer trends, financial assistance programs, charitable access, related resources, regional level, and alternative resources. Assists in obtaining insurance approvals/denials and/or appeals for therapy. Assists patients and HCP with processing applications for Copay Assistance/Reimbursement and Patient Assistance Programs. Assists with ordering/triaging prescriptions for patients or HCP. Provide education to patients and health care providers, regarding insurance requirements, options, and limitations necessary to initiate therapy. Provide education on relevant disease/product information.
- Assist the Case Management team as the escalation point of contact from receipt to resolution.
- Lead training on program specifics for new hires. Lead refresher training as needed individually or for the team as a whole. Assist leadership in training material documentation and training agendas.
- Identify and recommend process improvements to support operational efficiencies. Effectively shares knowledge with other team members through orientation training, case studies, and consultation for complex cases.
- Assist leadership team with SOP/WI documentation updates and control.
Qualifications
- Experience in a combination of home care management, case management review, utilization review, social service support, insurance reimbursement, and patient advocacy, preferred. • In-depth understanding of health care insurance benefits, relevant state and federal laws, and insurance regulations, highly desired. Experience with data entry/computer literate skills preferred.
- Strong verbal and written communication skills, including effectively communicating with clients/providers/patients and employees of ConnectiveRx professionally and courteously. • Mediation, and problem-solving skills. Spanish speaking skills are a plus. • Ability to control and own escalations from beginning to resolution. • Proficient in all MS Office applications
- Bachelor’s Degree (or equivalent) in a related area with a focus on Health Care, Social Work, or Nursing, preferred. A minimum of 2 years of equivalent work experience may be substituted for a degree.
- A minimum of 2 years of recent experience in the case management process, is preferred. Prefer to have experience in a hub environment, healthcare claim adjudication, medical benefit handling, specialty pharmacy, third-party billing, and/or provider issues.
Communication (Oral & Written)
Ability to listen actively and communicate key issues respectfully. Understand the need to share only relevant information. Ability to adapt to different audiences, ensuring that the message is clearly articulated.
Service Orientation
Anticipate, identify, and address the needs of customers/clients, sometimes before those needs are voiced. Actively looks for ways to help people; ability to be thoughtful, and empathetic to the needs of others. Is prompt and courteous in ensuring that the customer's immediate needs or complaints are satisfied. Focuses on improving the level of service provided to external and internal customers.
Process Knowledge
Identifies, documents, and monitors key processes needed to achieve successful business results. Maps and document processes. Develops a framework for process improvement. Identifies and documents processes within the area of responsibility. Seeks guidance on aspects of the process that are out of immediate scope. Drafts procedures that comply with the process Implement process improvement recommendations within the context of overall business processes. Recommends and advocates substantive process enhancements and assesses both internal and external implications.
