The Care Management Specialist is responsible for establishing and maintaining relationships with providers, patients, families and vendors of Fairview Partners, as well as serving as the liaison between Fairview Partners and the health plans for all community enrolled members. The Care Management Specialist directly supports Fairview Partners Care Coordinators.
Serve as a liaison to patients, vendors, providers, and health plan representatives to resolve issues related to billing and health plan referral verification:
Understands the guidelines and processes within each health plan surrounding claims payment for patient referrals.
Assists case managers or providers with utilization, authorization, and claims payment as appropriate and requested.
Coordinates and facilitates services as directed by the Care Coordinator.
Performs, understands and can explain functions related to the referral process of patients:
Approves/Directs patient referrals to appropriate setting.
Understands benefit structure of each contracted health plan.
Communicates directly with vendors, clinics and payers or as needed to patients.
Responsible for oversight of monthly member reporting:
Reviews health plan member reports for accuracy which ties to monthly capitation payments from health plans.
Works with the health plans and care coordinators to correct discrepancies and appropriately assigns members to correct care system.
Utilizes Excel and Access database to report new member information to providers and internal entities of Fairview.
Coordination of Member Care:
Assists the Care Coordinators in coordinating and ordering services for community members. This includes working with various home care agencies and community agencies to assure the appropriate services have been scheduled.
Researches community resources for Fairview Partners members and develops relationships with new vendors in order to utilize their services on an on-going basis.
Documents member information using EPIC and the Department of Human Services reporting system.
Monitors and processes changes to member's health plan status, agency updates, and other internal tracking spreadsheets.
Assists members in transportation, appointment, and DME & supply requests.
Organization Expectations, as applicable:
Demonstrates ability to provide care or service adjusting approaches to reflect developmental level and cultural differences of population served
Partners with patient care giver in care/decision making.
Communicates in a respective manner.
Ensures a safe, secure environment.
Individualizes plan of care to meet patient needs.
Modifies clinical interventions based on population served.
Provides patient education based on as assessment of learning needs of patient/care giver.
Fulfills all organizational requirements
Completes all required learning relevant to the role
Complies with all relevant laws, regulation and policies
Performs other duties as assigned.
Two to four years of recent experience in a health care setting.
Two to three years of recent experience with Microsoft Word, Excel and Access.
Four years of experience in a health care setting.
Three years of experience with EPIC, Microsoft Word, Excel and Access.
Previous experience with referrals processing in medical office.
Additional Requirements (must be obtained or completed within a period of time):
Knowledge of third party payers, billing procedures and insurance.
Ability to work independently and exercise independent judgment.
Fairview Health Services