Ancillary Services Case Manager - JHP

Job Details

Job Description

Why Choose Jefferson Health Plans?

We are an award-winning, not-for-profit health maintenance organization offering Medicaid, Medicare, and Children's Health Insurance Program (CHIP) plans that include special benefits to improve the health and wellness of our members. We are committed to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential.

While this job currently provides a flexible remote option, due to in-office meetings, training as required, or other business needs, our employees are to be residents of PA or the nearby states of DE or NJ.

Perks of JHP and why you will love it here:

• Competitive Compensation Packages, including 401(k) Savings Plan with Company Match and Profit Sharing
• Flextime and Work-at-Home Options
• Benefits & Wellness Program including generous Time Off
• Impact on the communities we service

We are seeking a talented and enthusiastic Ancillary Services Case Manager to join our team!

Work under general supervision to assure cost-effective, quality patient care management for DME, homecare, home infusion, hospice at home, shift care, medical day care, transportation, and outpatient rehab services (including waiver programs, occupational therapy, and speech therapy and physical therapy).

As the Ancillary Services Case Manager, your daily duties may include:

• Process/review requests for durable medical equipment (DME), home care, home infusion, hospice at home, transportation, and outpatient rehab services such as occupational therapy, physical therapy, speech therapy shift care, and medical day care.
• Evaluate and authorize home care, home infusion, hospice at home, DME, transportation, and outpatient rehab requests for proper medical management and cost-effectiveness.
• Manage authorization requests received via 278 transactions via the provider portal and right fax queue
• Within the scope of required education and training, provide a clinical review for appropriateness of care. Utilization of InterQual criteria and Health Partners Criteria will be a source of review and standard for prior authorization.
• Coordinate with discharge planning, UM, and SNU to facilitate timely approval and coordination of services.
• Provide ongoing case management with a focus on preventing admissions and ER visits.
• Provide written and oral communication to members and providers for approvals/denial of services.
• Select and complete with appropriate language letters to providers and members.
• Track assigned cases for timely reviews/updates and ensure decisions are reflected in case documentation.
• Identify duplication of services and opportunities for improvement.
• Function as a liaison between ancillary providers and members
• Provide telephone service promptly and courteously.
• Consults with Medical Directors for medical director review and medical necessity determinations.
• Meet specified timeframes established by regulators (DHS, NCQA, DOH, and CMS).
• Identify expanded and continuity of care services and track them for the transition of care.
• Accurately code all services using appropriate ICD-10, CPT, and HCPCS coding systems.
• Serves as liaison to customer service representatives, grievance & appeals staff, and other internal staff departments.
• Assists and supports all related processes, including developing policies, procedures, and process improvement efforts as assigned.
• Participate in on-call program

Qualifications

• 2+ year's clinical nursing experience.
• Homecare and outpatient rehab services experience preferred. Experience working in managed care environment preferred.
• Experience with Medicare/Medicaid populations a plus.

Skills, We Value:

• Knowledge of medical necessity principles, including clinical criteria
• Knowledge of InterQual
• Computer literacy, including familiarity with Windows and Microsoft Office programs
• Ability to work independently
• Ability to work efficiently, with excellent time management skills
• Excellent communication skills both verbal and written
• Ability to work well with all types of providers/members
• Ability to maintain professional demeanor and confidentiality
• Sensitivity to the needs of every individual to be treated with respect and fairness

Work Shift

Worker Sub Type

Primary Location Address

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.