Acts as Subject Matter Expert in collaborating with Medical Directors, PAC Clinical Care Coordinators, PAC facilities, Provider Engagement, Client Services, and leadership related to Post-Acute Care medical utilization assignments during secondary reviews. Monitors PAC compliance trends and delivers findings to Supervisor.
Analyzes operating ODAG reports, updates and processes ODAG findings to ensure business SLAs and regulatory turnaround times are met while adhering to CMS, state and contractual policies and procedures. Works alongside nurses to ensure efficient delivery of regulatory managed care notification letters to Servicing Providers and members, monitors and processes provider requests related to Medical Director Recommendations delivering adverse determinations, and facilitates direction to providers for first level of appeal requests. Demonstrates understanding of the Initial and Concurrent Review processes and assists the PAC training team with MD Unable to Approve (UTA) processes as well as mentoring field Care Coordinators and Servicing Providers with MD concurrent extensions.
Direct responsibilities and duties also include:
Identify and report to Supervisor inefficiencies with processes
Research and compile information for complex cases and client/provider complaints Oversight/execution of frontline telephonic queue monitoring and operating translation portal,Record accurate documentation from clinical team collaborations, scheduling of Post Determination Conversations, scheduling of Medical Director Rounds, and requesting clinical data for completion of conditional MD Recommendation reviews. Triage of referrals Satisfy clinical requests from PAC Team related to MD RecommendationsExecution of Expedited Referral requests after MD final determination New service request creation Other duties as assigned
Minimum Experience Required
High School graduate with diploma or equivalent Medical Assistant/Medical Technician/License Practical Nurse (LPN) preferred
One year of work experience
Call center experience preferred2 or more years of experience in healthcare call center or customer service preferred
Various schedules to cover operating hours (7AM 7PM CST) Maintain flexibility to variations in work volume/work schedule, which sometimes require extended working hours. Occasional weekend/after-hours coverage may be required.Position is located at the Franklin, TN office
Time-management: Ability to effectively manage one's time and resources to ensure that work is completed efficiently. Excellent organizational skills
Communication: Ability to provide clear verbal and written information via in-person, email, and phone to customers, co-workers, and leadership
Critical-Thinking/Decision-making: Ability to choose a course of action or developing appropriate solutions by identifying and understanding issues, problems, and opportunities
Autonomy: Ability to work independently with little to no supervision
Ability to complete special projects or other duties as assigned
Proficient with various applications or software, such as: Microsoft Outlook, Word, Excel, and PowerPointExperience with PAC Manager applications a plus