Care Management Specialist
JOB TITLE: Care Management Specialist
PROGRAM: Care Management
FLSA STATUS: Non-exempt
JOB SUMMARY: The Care Management Specialist works closely with the Supervisor, Billing Department, and other internal programs/external entities to obtain authorization of services rendered by the agency to ensure timely reimbursement. The Care Management Specialist also ensures the agency provides quality services and complies with agency, state and federal guidelines.
DUTIES AND RESPONSIBILITIES :
- Responsibility #1 – Authorizations - 80% of time
- Reviews assessments and other clinical documentation in the client’s record and completes authorizations for services for all agency programs and transmits them to the Accountable Services Organization (ASO) within 48 hours of assignment.
- Responsibility #2 – Quality Assurance Reviews - 10% of time
- Completes/conducts quality assurance reviews of client treatment plans at the time of authorization for services to ensure all needed and performed services are on current plan. Reports any concerns to the staff or supervisor.
- Performs quality assurance checks when reviewing clinical documentation in the client’s record to ensure quality services and compliance with agency, state and federal guidelines. Reports concerns to the staff, direct supervisor and the program supervisor/director.
- Responsibility # 3 – No Authorization Failed Claims – 10% of time
- Processes failed claims requiring authorization for assigned programs and determines reason(s) for failure to obtain the authorization per agency deadlines. Resolves issues related to authorization needed for billing to occur within agency timelines and communicates with Billing Department, supervisors and/or programs as applicable.
- Responsibility # 6- General Responsibilities
- Maintains confidentiality for all indirect/direct service in accordance with agency policies, HIPAA policies and confidentiality laws.
- Maintains clinical records in accordance with agency policies.
- Ensures timely completion of agency required trainings/workshops.
- Completes other responsibilities and tasks as may be assigned. ?
KNOWLEDGE, SKILLS AND ABILITIES
- Understanding of community behavioral health and state and federal guidelines to provide services.
- Understanding of Utilization Management Processes.
- Understanding of Microsoft Office programs.
- Strong clinical skills.
- Strong auditing skills.
- Strong verbal and written communication skills.
- Strong typing and computer skills.
- Ability to work independently and manage time to complete assignments within set deadlines.
- Ability to read and synthesize biopsychosocial and clinical data to complete authorizations and treatment plans and ensure compliance with guidelines.
- Ability to interpret guidelines and apply to various clinical cases.?
- Completes the authorization process for a minimum of 70 Non-Intensive Outpatient individuals, or 35 Specialty Services, as assigned, for every 40 hours worked.
- Completes a CONNECTS authorization within 48 hours of assignment and completes the CONNECTS Assignment Form for every connects request that is processed.
- Follows-up every 72 hours on any outstanding requests, i.e. with clinical staff and billing, to obtain needed information to obtain authorizations for billed services/failed claims.
- Reviews Failed Claims if assigned and completes a Failed Claims Resolution Form for every failed claim worked.
- Education – Master’s Degree in a Social Services Field from an accredited college or university or a Bachelor’s Degree in a Social Services field and five (5) years of experience in the behavioral health field.
- Licensure/Certification – Not required.
- Experience – Three-years (3) years of experience in the behavioral health field with a Master’s Degree or five (5) years of experience with a Bachelor’s Degree.
- Education – Same as minimum.
- Licensure/Certification – Licensure at Associate level or above preferred.
- Experience – Prefer experience in community/governmental behavioral health settings.