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Care Management Analyst, On-Site, Clk Street Medicine

Located in beautiful Northern California, Adventist Health Clear Lake has been a leading healthcare provider in Lake County since 1968. We are comprised of a 25-bed critical access hospital and provide primary and specialty care services at clinics throughout the area to best serve our community. Lake County is home to Clear Lake, California's largest natural freshwater lake, surrounded by charming small towns, beautiful mountains, vineyards and orchards. This area is perfect for outdoor enthusiasts, with some of the best bass fishing, rural trails for hiking and biking, all the while being only two hours from the San Francisco Bay Area, Sacramento Valley or Pacific Coast.

Job Summary:

Reviews patient encounters and medical records to determine if improvement opportunities exist through either technological or communication enhancements. Supports the execution of system-wide strategic initiatives, process re-design, root cause analysis, metric/report development as it relates to clinical reviews and denial management. Analyzes, monitors, reports findings, and provides recommendations on key report sets to Adventist Health leadership and utilization management committee. Works closely with key departments (e.g., on-site care management, medical staff, HIM/coding, patient financial services, etc.) to review and obtain the medical documentation required to streamline the adjudication process. Tailors communications to respective audiences (e.g., system leaders versus regional leaders) to ensure that specific mitigation action plans are created and implemented. Supports and facilitates the design as well as implementation of utilization management data collection and reporting methodologies. Develops analytic models and trending displays and dashboards to inform executive leaders, oversight committees and Key stakeholder of process and outcomes of high priority metrics, functions and opportunities for improvement and progress to goals. Understands, utilization management and its impact on claim adjudication.

Job Requirements:

Education and Work Experience:

Associate's/Technical Degree in finance or business or equivalent combination of education/related experience: Required
Bachelor's Degree in mathematics, statistics, economics or finance or equivalent combination of education/experience: Preferred
Three years' acute care hospital revenue cycle experience: Preferred

Essential Functions:

Creates a regularly scheduled report set of key metrics (e.g., denials by category and market, overturned denial rate, write-off rate, etc.) related to the case management & revenue cycle team that is distributed to Adventist Health leadership. Uses data to investigate areas, such as clinical denials, to determine root-cause and subsequent mitigation action plans.
Collaborates with necessary personnel or departments to implement action plans, using either verbal or written communication to emphasize importance of an issue. Prioritizes issues based on timeframe to implement, ease of implementation, and overall impact.
Samples encounters that have received either a clinical or billing denial related to case management type denials (e.g., referral, pre-authorization, medical necessity, non-covered service, etc.) and validates the denial reason.
Assists with developing and maintaining performance tools for ongoing reports and acts as a liaison to the utilization management committee. Identifies and escalates consistent issues/trends with payers to AH leadership.
Keeps a pulse on any regulatory changes and payer policies that may affect Adventist Health. Maintains confidentiality of information in compliance with hospital policies and HIPAA.
Performs other job-related duties as assigned.

Organizational Requirements:

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.

Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.

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