Clinical Resource Coordinator

Position Summary:

Major Position Responsibilities:

The position characteristics reflect the most important duties, responsibilities and competencies considered necessary to perform the essential functions of the job in a fully competent manner. They should not be considered as a detailed description of all the work requirements of the position. The characteristics of the position and standards of performance may be changed by TCMC with or without prior notice based on the needs of the organization.

• Collaboration of Clinical Resources
• • Prepares 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.
  • 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 IMFM 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 throughout 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 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 utilization review team to make sure all are aware of denials real time.
  • Supports staff and leadership to meet department objectives.
• Database management
• • Assists 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 (IMFM).
  • Provide secondary IMFM to patients according to policy and document in electronic medical record.
  • 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 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 operations
• • Ensures CM/DCP/UM staff have appropriate resources and information to expedite smooth transition 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 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.
  • 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 up
• • Confirm discharges from previous day and ensure that cases are closed in Careport.
  • Prepare discharge paperwork for planned discharges, including documenting post-acute information in the electronic medical record 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 electronic records 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 competency
• • Obtain 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 electronic medical record.
  • Researches and assists in the denial process-gathers documentation for the director, and attending physician.
• Patient placement
• • Proactively 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 as appropriate.
  • 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 appropriately when placement is complete.
• Professional development
• • Actively 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.

Qualifications:

• 2 Years hospital experience, preferred.
• 2 Years Medi-Cal experience, preferred.
• 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.

Education:

• H.S. Diploma or Equivalent, required.
• Additional health related education, preferred.
• Successful completion of Medical Assistant Program or equivalent, preferred.

Each new hire candidate who is offered employment must pass a physical evaluation, urine drug screen and pre-employment background checks before starting work.

• 
  Salary/Hourly wage range for this position is posted. Actual pay will be determined based on verified experience as well as internal equity.

TCHD is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex (including pregnancy, sexual orientation, or gender identity/expression), age, marital status, status as a protected veteran, among other things, or status as a qualified individual with a disability.