NextStep Care QA & Compliance

– a place where you’ll be valued, recognized and rewarded for the vital work you do each day. We’ll surround you with a strong team and leadership that supports every aspect of your life – both inside and outside of our centers. And you’ll get to practice your passion  in a non-profit, mission-driven organization that’s known for the highest level of care in our communities

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Maintains accurate member records in electronic health record, including Level of Care (LOC) Prior Authorization numbers and submission dates, approval/denial dates and effective/expiration dates.
• Retrieves daily LOC approvals and denials from the Medicaid portal (GAMMIS) and maintains accurate data in software tracking tools with the approval status.
• Communicates effectively with operations, assessment department, health care navigation team and external stakeholders regarding approvals and denials. Ability to manage multiple tasks and meet deadlines in a fast-paced environment.
• Knowledge and understanding of Medicare, Medicaid, Private Pay, and third-party reimbursement.
• Maintains appropriate information in software tracking tools regarding transmission of patient information
• Knowledge of care management and Medicaid waiver admissions and assessment requirements. May process requests for records from outside entities in conjunction with members of the Quality department.
• Honors patient’s rights to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to wage complaints.
• Complies with Corporate Compliance Program.
• Reports job-related functions/tasks that involve occupational hazards including exposure to blood and body fluids and others as necessary.
• Follows established safety regulations, including fire protection/prevention, smoking regulations, infection control, etc.
• Complies with all Privacy & Security programs.
• Obtains pertinent information from care management and assessment team members.
• Verifies that assessments are reviewed, submitted, and tracked through internal systems.
• Ability to evaluate patient information to ensure information included is accurate, complete and necessary to support patient care or to facilitate billing.
• Strong attention to detail and possesses good organizational skills.
• Proficiency with Electronic Health Record technology, Smart Sheet, Medicaid, Medicare and Private Insurance portals.
• Maintains listing and Electronic Health Record with submission details and status.
• Promotes the image and reputation of the System by exhibiting servant leadership and providing direct and open lines of communication.
• Contributes to the work of committees, workgroups, project management, and other collaborative efforts of the System.
• Communicates effectively and appropriately across departments and programs.
• Documents necessary communication in electronic case management system including entering notes in database.
• Navigates client databases and program specific spreadsheets/documents.
• Navigates system case management as part of a patient centered transition of care.
• Knowledge of health system services available through case management and other health service lines.
• Attends and participates in continuing education programs to maintain knowledge of industry specific changes and trends.
• Attends and participates in mandatory in-service training.
• Performs other duties as necessary to ensure the success of the System.

SKILLS AND ABILITIES

• Customer service oriented.
• Excellent organizational and prioritizing skills required  
• Should possess good marketing and communication skills.
• Computer skills required.

MINIMUM QUALIFICATIONS

• High School Diploma or equivalent required
• Three years of experience in healthcare and previous Medicaid or case management experience preferred
• Valid Driver's License

SUPERVISORY RESPONSIBILITIES

None

LANGUAGE SKILLS

Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or associates of the organization.

MATHEMATICAL SKILLS

Ability to add, subtract, multiply and divide in all units of measure, using whole numbers, common fractions, and decimals.

REASONING ABILITY

Ability to apply common sense understanding to carry out instructions furnished in written, oral or diagram format.  The ability to deal with problems involving several concrete variables in standardized situations.

COMPUTER APPLICATION SKILLS

This job requires proficiency with the following computer applications:

Microsoft Outlook                  Microsoft Excel                      Microsoft Word

CERTIFICATES, LICENSES, REGISTRATIONS

Please see minimum qualifications

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an associate to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the associate is regularly required to sit, talk or hear.  The associate frequently is required to walk.  Use hands to finger, handle or feel and reach with hands and arms.  The associate is occasionally required to stand.  Specific vision abilities required by this job include close vision, distance vision and the ability to adjust focus.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an associate encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually quiet.

EEO / M / F / D / V / Drug Free Workplace

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