Inpatient Case Management Authorization Specialist

Overview

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At Emory Healthcare we fuel your professional journey with better benefits, valuable resources, ongoing mentorship and leadership programs for all types of jobs, and a supportive environment that enables you to reach new heights in your career and be what you want to be. We provide:

 

• Comprehensive health benefits that start day 1
• Student Loan Repayment Assistance & Reimbursement Programs
• Family-focused benefits
• Wellness incentives
• Ongoing mentorship, development, and leadership programs
• And more

Description

We're seeking an Inpatient Case Management Authorization Specialist (CMAS). This individual has 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 payer's 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 Emory's Electronic Health Record based on payer's 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 Emory's 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