Supervisor of Pre-Certification Support
4 weeks ago
The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.
Oversees all aspects of the Precertification Support services regarding MAPD precertification requirements. The supervisor oversees and ensures compliance with CMS regulations and departmental policies including regulatory timeframes (standard/expedited time frames, org determination outcomes, and communication, inter-rater reliability); provides direction for complex cases; monitors pending cases; reviews and educates staff on criteria changes (including InterQual, Local Coverage Determinations (LCD), National Coverage Determinations NCD); and acts as a liaison with other departments.
Works closely with Supervisors of Case Management and Pre-Certification on all initiatives and unit functions.
- Graduate of a health care associate degree program. Bachelor's degree in business, human services, or a health-related field preferred.
- Minimum 3 years of Managed care experience in the areas of utilization management and/or case management required.
- Proficiency in Microsoft Word, Excel, and Windows operating systems.
- Excellent customer service, oral communication, writing, and typing skills. Excellent telephone assessment skills.
- Working knowledge of utilization management processes Knowledge of Federal and State regulations and managed care regulations and concepts.
- Ability to provide appropriate support and direction to facilitate collaborative efforts toward accomplishing Department goals and objectives.
- Demonstrates knowledge/ability of Institutional goals and changing trends in healthcare and cost factors in delivering patient care.
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