**Facility:** Grossmont Hospital **City** La Mesa **Department** **Job Status** Regular **Shift** Day **FTE** 1 **Shift Start Time** **Shift End Time** H.S. Diploma or Equivalent **Hours** **:** **Shift Start Time:** 7 AM **Shift End Time:** 5:30 PM **AWS Hours Requirement:** 10/40 - 10 Hour Shift **Additional Shift Information:** **Weekend Requirements:** As Needed **On-Call Required:** No **Hourly Pay Range (Minimum - Midpoint - Maximum):** $25.966 - $32.457 - $38.948 The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.  The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices. **What You Will Do** This position supports case management/social work staff to meet department objectives, facilitate effective communication between department staff and the internal and external customers to the department, including but not limited to the business office, revenue cycle, payors, long term care, sub-acute facilities, and patients/families. Reviews complex request for medical care and services, if part of the discharge plan, inpatient admission, skilled nursing facility admission, including requests for outpatient care, retrospective claim review, durable medical equipment, medication issues and acquisition, home health, in accordance with payer guidelines. To provide support and help facilitate care coordination services provided by the Hospital Case Manager. This position is responsible for the care and services delivered to a specific hospital. **Required Qualifications** + H.S. Diploma or Equivalent **Preferred Qualifications** + Additional health related education + Successful completion of Medical Assistant Program or equivalent + 2 Years hospital experience. + 2 Years Medi-Cal experience. **Essential Functions** + Collaboration of Clinical ResourcesPrepares the inpatient census. Confirms report accuracy, makes modification as warranted to reflect accurate and current information.Verifies current insurance plan eligibility. Reports statistics to the Director of Case Management.Prepares paperwork for the Hospital Case Managers such as the actionable dashboard.Reviews patient list and prioritize/plan for the day.Generates phone calls to physician offices, health plans, and providers to assist in care coordination under the guidance of case managers including reviewing patient's need and condition with Skilled Nursing Facilities and Home Health Agencies for placement. Contributes to the continuous improvement initiatives of the hospital case management team to deliver quality interventions in a timely manner.Deliver IMM letter to patient in accordance with hospital policy and procedure.Assist the Hospital Case Manager by relaying information regarding patient demographics and the distribution of lists of contracted facilities for Skilled Nursing.Maintains current communications with insurance and case managers.Maintains current phone message log of payor phone calls.Initiates and proactively collaborates with staff regarding frequently utilized community resources.Acts as facilitator between payors and case managers.Ensures case managers are updated daily and thought out the day as needed.Schedules duties outside the office and breaks in collaboration with other assistants to ensure phone is answered in person at all times.Keeps director, and leads apprised of status, including delays or inability to complete tasks.Proactively notifies and reminds staff of meetings.Maintains knowledge and skills required to perform co-assistant's specific duties (generation of a.m. paperwork for case managers, track case management assistant assignment logs as needed-temporary assistance, vacation coverage.)Responsible for timely and accurate retrieval and appropriate action on departmental phone messages and necessary fax communication.Assist case managers with ordering Durable Medical Equipment, following up with suppliers, and processing needed paperwork.Work closely with revenue cycle to ensure the latest reimbursement and contract information is available to the case managers.Work closely with the revenue cycle to make sure all are aware of denials real time.Supports staff and leadership to meet department objectives. + Database managementAssists with the processing of letters of appeal or denial.Share with patient access list of patients who have not received initial Important Message from Medicare (IMM) and document initial IMM into Cerner.Provide secondary IMM to patients according to policy and document in Cerner.Prepare and send medical records in case of active appeal, especially from Medicare QIO.Follow up on appeals and decisions, particularly from Medicare QIO.Prepare databases and written reports for leads, manager, and director in a timely manner.Consistently is up to date and current on all action taken on denials.Initiates and participates in the creation and development of forms and lists.Assist case managers and physician advisors with denial cases, setting up peer to peer reviews as needed. + Department operationsEnsures CM/DCP/UM staff have appropriate resources and information to expedite smooth transition to through continuum and optimize third party payer reimbursement.Develops and maintains compressive resource and reference lists per department needs.Monitor authorization for all patients in-house to ensure reimbursement and payment for correct level of care.Maintains communication with community SNF and post-acute agencies regarding changes in nursing services, payor requirements, and physician coverage.Schedule requested appointments for follow-up care.Fax orders and needed chart information for continued medical care. Contact payor to obtain patient clinic info if required.Provide needed clinical information to payors for payment purposes as well as for continuum of care post-acute or hospital to hospital transfers).Monitor completion of retro reviews and notifies lead of reviews pending by noon the second business day of the request.Proactive in obtaining current information and incorporating new agencies into resource lists on the share drive.Assist with reporting of specific payor as appropriate and needed.Provide needed documentation for Medi-Cal TAR free process, and complete TARs timely for those patients who are not appropriate for the TAR free process.Attends department meetings.Initiates and participates in huddles and quality improvement activities.All work is consistently completed on time and in a timely manner. + Discharge and patient follow upConfirm discharges from previous day and ensure that cases are closed in Ensocare.Prepare discharge paperwork for planned discharges, including documenting post-acute information in the depart summary as appropriate.Set up the appropriate transportation through contracted ambulance service when needed.Generates phone calls to patients, physician offices, health plans, and providers to assist in care coordination under the guidance of case managers including reviewing patient's needs and condition with skilled nursing facilities for placement.Facilitates setup, delivery and or implementation of the following: Skilled Nursing Facility, durable medical equipment, home health agency, scheduled follow-up procedures and medication delivery.Updates CACM with patient discharge information.Facilitates the distribution of patient information to the Skilled Nursing Facility to include the patient's chart notes (progress notes, physician orders, H&P) and patient's need for transportation (dialysis, appointments, etc.) + Industry skills and competencyObtain detailed benefit coverage for complex requests specific to patient plan coverage.Investigate and follow-up on all eligibility issues in accordance with hospital guidelines.Performs review of all prior authorizations, entering into CACM.Researches and assists in the denial process-gathers documentation for the UR lead, director, and attending physician. + Patient placementProactively identifies requests for post-acute placement, anticipates volume as possible.Reminds case management of needed forms for post-acute placement and durable medical equipment.Sends out referrals for post-acute placement and keeps case manager informed of acceptance. Makes follow up calls as needed.Obtain authorization from payers for post-acute care with clinical information obtained from case manager.Send/fax/follow up on patient prescriptions with pharmacies.Create packets for post-acute or hospital to hospital transfer, using most current forms and processes and delivering to appropriate nursing unit, including disc if needed for acute to acute transfer.Arrange transportation as needed, collaborating with case manager, payor, facility and providing PCS form if required or requested.Assist in locating accepting facilities/home health agencies for low income patients.Assure that required SNF call list is completed each weekday for patients on administrative days.Documents accepting home health agency and physician appointments in the depart summary.Coordinate home infusion and home health with case manager.Answer and manage phone calls from payors, patients and families regarding discharge plans.Closes cases in Ensocare appropriately when placement is complete. + Professional developmentActively identifies gaps in skills and competencies and participated in seminars/classes to enhance gaps.Attends and actively participates in department/team process/quality improvement activities.Actively participates in all-staff meetings and stand-ups. **Knowledge, Skills, and Abilities** + Bilingual preferred. + Knowledge of hospital payors preferred. + General filing knowledge. + Demonstrated proficiency in Microsoft Word, Microsoft Excel, Microsoft Outlook, and other software programs.Excellent organization, managerial and time management skills with the ability to multi-task. + Excellent analytical, problem solving and supervisory skills, knowledgeable of medical terminology, and current standards of clinical practice, professional counseling, mentorship and resource allocation. + Knowledgeable in the use of ICD-10, CPT4, and HCPC coding systems. + Proficient in typing and computer data entry (45 wpm). + Excellent verbal and written communication skills. + Ability to read, speak, and hear English clearly. + Able to work independently in research and decision making with minimal direction from higher level of staff. Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class