Job ID: 97529 Date posted: August 17, 2019
- SRS Administration
- Utilization Management
- Clerical Jobs
- Day Job
- Per Diem
Care Specialist will review complex requests for medical care and services, including requests for outpatient care, elective inpatient admission, skilled nursing facility admission, retrospective claim review, medical equipment, and home health in accordance with Sharp Rees-Stealy Medical Group (SRS) referral guidelines. Provide support and facilitation of care coordination services provided by the Case Managers (Levels I-IV) to members.
Obtain detailed benefit coverage for the more complex requests for service specific to member plan coverage. Apply the principles of SRS guidelines and Health Plan benefit guidelines to approve referrals designated at the CC level. Check eligibility status. Investigate and follow-up on all eligibility issues in accordance with health plan and SRS guidelines.
Coordinate, review and process the more complex referrals for prior authorization for medical care and services, including emergency room, urgent care visits, inpatient admission, outpatient care, durable medical equipment, home care and other
miscellaneous services for the efficient and effective delivery of patient services.
Perform reviews of the more complex prior authorization referrals.
Obtain necessary medical information by following the SRS PAI process.
Identify and refer requests for review by higher level staff (CM and above) within department turn around time (TAT) standards.
Research and assist in the denial process; gather documentation after review by the Medical Director, ensure packet is complete, assess and select the appropriate denial reason, and maintain mandated TAT for denials.
In addition, the Care Specialist - SRS will perform the following functions: obtain and gather clinical information from multiple sources including use of Sharp applications to retrieve patient medical records for review by Case Managers; maintain and
organize data, prepare and distribute reports within designated timeframe; manage correspondence to members and PCP, health plans and other service providers; make phone calls to members, physician offices, health plans, and providers to assist in care
coordination under the guidance of case managers; organize and maintain case files; provide clerical support and assistance to the Case Management team; contribute to the continuous improvement initiatives of the Case Management team to deliver quality
and timely interventions; maintain data and run reports in an organized and timely manner; and organize and implement daily work plan for chronic disease activity schedule under the guidance of chronic care managers
With 400 primary and specialty care physicians providing care at 20 facilities throughout the region, Sharp Rees-Stealy Medical Group is one of the largest, most comprehensive medical groups in San Diego County, and is recognized for excellence in-patient satisfaction and clinical care. For patient convenience and improved coordination of care, Sharp Rees-Stealy offers services like laboratory, radiology, physical therapy and urgent care within each clinic or nearby.
Sharp Rees-Stealy has also opened two remarkable state-of-the-art medical office buildings. One located in Downtown San Diego and the other in Sorrento Mesa. Both will provide their communities with leading edge care for decades to come.
This position is located at Copley Drive, San Diego County
Per Diem, 8hr shift: 8:30am-5:00pm
Required Skills and Qualifications
- Excellent organizational and time management skills including the ability to multitask. Excellent analytical and problem solving skills.
- Proficient in medical terminology and current standards of clinical practice. Proficient in use of ICD-9, 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. Ability to work independently in research and decision making with minimal direction from higher level staff.
- Occasional travel between Sharp HealthCare facilities and provider offices; must provide own transportation.
- Three (3) years minimum working in the managed health care field, preferably HMO or delegated risk medical group/IPA setting.
- One (1) year experience with medical coding and data entry, preferably in a managed care environment. Successful completion of ICD-9 and CPT coding classes, or equivalent work experience.
- Successful completion of Medical Assistant Program or equivalent preferred.
Additional physical requirements may be discussed at the time of interview.
Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability.
“After nearly 10 years of working here, it's still one of the hardest jobs I've ever loved. If you find a niche here, you'll be working with some of the smartest in the industry. This is where they'll respect you for thinking outside the box and kindness matters. They expect consistency and hard work, but pay you well to do it.”