This position incorporates all Care Coordinator functions within the CareCentrix HomeSTAR Program including, collecting and verifying clinical and demographic information, hospital discharge dates, initial authorizations, staffing of services with HHA and patient / provider education for HomeSTAR Program. The HomeSTAR Care Coordinator educates and gathers information using scripted clinical and non-clinical questions and is able to provide appropriate issue resolution and/or escalation when needed. The position works under moderate supervision, with clinical oversight and input.
• Coordinates the setup of cases in different CareCentrix applications for HomeSTAR Program referral process.
• Initiates outbound calls to hospitals, discharge planners, physicians, and home health agencies providing education regarding the benefits of the HomeSTAR Program.
• Determine discharge status of referred patients by contacting discharge hospitals. Researches and determines location and status of referred patients.
• Staffs HomeSTAR referrals with HomeSTAR designated agencies, identifies if a new HomeSTAR agency is needed and alerts network operations of recommended addition.
• Interacts with physician offices to obtain home health orders for HomeSTAR services, monitors compliance of documentation submission and coordinates the retrieval of home health agency nurse documentation and surveys.
• Participates in and contributes to performance and process improvement activities.
• Involved in the collection, verification and confirmation of non-clinical information. Gathers structured clinical documentation. Is able to provide appropriate non-clinical issue resolution and escalation of issues when needed.
• Receives/responds to incoming calls from referral sources/potential patients, exchanges information to identify the patient’s needs and determines the Company's ability to meet them. Records the outcome of calls in the proper screen.
• Completes initial case set up process and consults applicable Payer Fact Sheets.
• Contacts health plans or payors to gather policy benefits/limitations and completes eligibility and benefits verification to ensure services provided will be covered by the carrier. (e.g., deductible amounts, co-payments, effective date, pre-existing clauses, levels of care, authorization, visit limitations, documentation required to process claims, etc.). Documents all communications and decisions into a computer database or on a manual form.
• Access payer fact sheets to determine if the terms of the contract are covered. Works with contracted providers and patients to identify potential solutions as problems are identified with payer sources.
• Contacts referral sources to advise them of referral status. Relays referral and utilization information to the appropriate HomeSTAR team member.
• Understands that timely and accurate documentation is critical to the success of CareCentrix.
• Coordinates provider service authorizations for immediate referral resolution.
• Ability to negotiate with providers when needed and stay within the guidelines.
• Must be committed to quality and high standards. Be able to provide issue resolution and escalation when appropriate.
• Works closely with health plans/payers and maintains strong business relationships.
• Participates in implementing / maintaining operational processes to ensure compliance to Company policies, legal requirements and regulatory mandates.
• Participates in special projects and performs other duties as assigned.
ATTRIBUTES / QUALIFICATIONS
This position requires excellent communication, customer service and problem solving skills, as well as the ability to effectively interact with all levels of management and a highly diverse clientele. Must have strong organizational skills and be able to effectively manage and prioritize tasks. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
• Abides by and demonstrates the company Mission – Vision – Values through both behavior and job performance on a day-to-day basis.
• Convey a strong professional image, exhibit interest and positive attitude toward all assigned work.
• Adheres to and participates in Company’s mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices.
• Reviews and adheres to all company policies, procedures, and the Employee Handbook.
• Must be able to remain in a stationary position 90% of the time.
• Occasionally move about the office to access file cabinets, office machinery, etc.
• Constantly operates a computer and other office productivity machinery (i.e., a calculator, copy machine, and computer printer).
• Frequently communicates via phone and email. Must be able to exchange accurate information in these situations.
• Occasionally lift items weighing up to 10 pounds.
High School Diploma or the equivalent plus a minimum of one year medical terminology or medical services experience required. Knowledge of basic spreadsheet / word processing / data entry preferred. Experience in a call center environment preferred. Knowledge of Utilization Management and URAC standards.
CareCentrix maintains a drug-free workplace in accordance with Florida’s Drug Free Workplace Law.