Inpatient Case Management Authorization Specialist

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Were seeking an Inpatient Case Management Authorization Specialist (CMAS). This individualhas a general understanding of insurance requirements as it relates to insurance verification notification authorization and collaboration. This role functions with minimal oversight and guidance in the Care Management Inpatient Department or Utilization Management Department with distinct responsibilities.

Primary duties and responsibilities:

Care Management Inpatient Department:

1. Assists the Care Management Inpatient team to timely transition patients into post-acute services within the allotted amount of reimbursable hospital days as determined by the clinical authorization obtained.

2. Submits referrals for securing post-acute care services as directed which may include Home Health Durable Medical Equipment Subacute Rehabilitation Inpatient Rehabilitation Facility Long-Term Acute Care Hospice or Long-Term Care.

3. Prioritizes work with minimal guidance for optimal reimbursement and to avoid financial risk to both patient and hospital.

4. Ensures proper use of Care Management Systems and display adherence with workflows which guide all responsibilities.

Utilization Management Department:

1. Verify insurance eligibility and submit notice of admission (NOA) for inpatient and observation admissions to the identified primary and secondary insurances based on the payers notification requirements and UR Department processes.

2. Verify completion of automated NOAs for appropriate insurances and if necessary will resubmit manually.

3. Submit appropriate admission and continued stay clinical documentation supporting services or care provided to insurances without access to Emorys Electronic Health Record based on payers preferred method and reimbursement methodology.

4. Secures reimbursement by confirming insurance authorization determination for the inpatient or observation admission through appropriate and required communication methods.

5. Will add approved bed days to Emorys Electronic Health Record as appropriate based on authorization and reconcile authorized versus actual days to secure reimbursement for provided care.

6. Prioritizes work with minimal guidance for optimal reimbursement and to avoid financial risk to both patient and hospital.

7. Display adherence with department processes which guide all responsibilities.

Compliance: Care Management Inpatient Department:

1. Ensure regulatory requirements are met as it relates to the delivery of Important Message from Medicare (IMM) Medicare Outpatient Observation Notice (MOON) Medicare Change of Status Notice (MCSN) and Medicare Hospital Issued Notices of Non-Coverage (HINNs) for Medicare beneficiaries as appropriate.

2. Maintains all required annual competencies metrics and fully participate and engage in department process improvements.

Utilization Management Department:

1. Maintains all required annual competencies metrics and fully participate and engage in department process improvements.

Collaboration: Care Management Inpatient Department:

1. Collaborates with insurance to initiate/request authorizations for post-acute care.

2. Provides effective and efficient proactive communication to internal and external customers.

3. Assists in collaborative efforts with the Utilization Management Department Revenue Cycle Care Management Medical Directors and other required departments.

Utilization Management:

1. Follow the UR Departments peer-to-peer workflow as appropriate.

2. Will inform the Patient Access Department and UM leadership of any discrepancies identified related to coordination of benefits and/or coverage as it relates to ineligible coverage non-covered services or out of network status.

3. Assists in collaborative efforts with the Care Management Department Revenue Cycle Utilization Review Medical Directors and other required departments.

Additional Responsibilities:

1. Ability to multi-task in a fast-paced environment while efficiently handling multiple priorities and ensuring deadlines are met.

2. May specialize in certain payors but overall is an insurance generalist within the department.

3. Assists with providing technical and clerical support as directed.

4. Performs other duties and tasks as assigned.

Minimum Qualifications:

• High School diploma or equivalent.
• At least two years of experience in a healthcare setting is required.
• Preferred Qualifications: Associate or Bachelors degree preferred. Experience - Two years of insurance verification authorization or related work preferred.

JOIN OUR TEAM TODAY! Emory Healthcare (EHC) part of Emory University (EUV) is the most comprehensive academic health system in Georgia and the first and only in Georgia with a Magnet designated ambulatory practice. We are made up of 11 hospitals-4 Magnet designated the Emory Clinic and more than 425 provider locations. The Emory Healthcare Network established in 2011 is the largest clinically integrated network in Georgia with more than 3450 physicians concentrating in 70 different subspecialties.

Emory is an equal opportunity employer and qualified applicants will receive consideration for employment without regard to race color religion sex national origin disability protected veteran status or other characteristics protected by state or federal law.

Emory Healthcare is committed to providing reasonable accommodations to qualified individuals with disabilities upon request. Please contact Emory Healthcares Human Resources at . Please note that one weeks advance notice is preferred.