Medical Case Review Specialist

5 days ago


Allentown, Pennsylvania, United States Pyramid Healthcare Inc Full time
Job Summary

This role is designed to provide exceptional care and support to those we serve by ensuring accurate information, timely communication, and compliance with local, state, and federal regulations.

About the Role

We are seeking a highly organized and detail-oriented Medical Case Review Specialist to join our team at Pyramid Healthcare Inc. The ideal candidate will have excellent communication skills, a strong work ethic, and the ability to maintain confidentiality.

Key Responsibilities

  • Perform admission, continued stay, and discharge reviews on all managed care clients to ensure accurate billing and revenue management.
  • Maintain positive relationships with referral sources and insurance companies through timely communication and proactive problem-solving.
  • Track admissions, continued stay, and discharge PCPC requirements for county referrals to ensure compliance with regulatory standards.
  • Develop and maintain an organized system of reporting to counselors when PCPC's are due and when review calls are to be made.
  • Stay up-to-date on current insurance eligibility information through EVS, Navinet, and other relevant systems.
  • Monitor Census for accuracy of funding to ensure optimal resource allocation.
  • Attend clinical staffing to obtain information for client reviews and collaborate with multidisciplinary teams.
  • Maintain daily UR database accurately to inform data-driven decision-making.
  • Perform Act 106 reviews and follow up appeals to ensure fair and timely resolution.
  • Track all county referrals for documentation of admission calls to maintain accurate records.
  • Participate in chart reviews to ensure proper paperwork is in place and compliant with regulations.
  • Collaborate with the Billing Department to reduce uncovered days of funding and investigate cases with insurance and referral sources to recuperate lost days of funding.
  • Report to the Assessment Manager on a weekly basis to provide updates on key performance indicators.
  • Manage self-pay clients and clients with copays, deductibles, coinsurance, and liabilities to reduce client balances.

Requirements and Qualifications

  • Bachelor's degree in a related field or equivalent experience.
  • Excellent communication, organizational, and problem-solving skills.
  • Able to maintain confidentiality and handle sensitive information.
  • Familiarity with medical terminology, appeal and denial processes, composition of medical records, and data entry (primarily Excel) is a plus.

Benefits

  • Competitive salary range: $55,000 - $70,000 per year, depending on experience.
  • Medical, dental, and vision insurance.
  • Flexible spending accounts.
  • Life insurance.
  • Paid time off.
  • 401(k) with company match.
  • Tuition reimbursement.
  • Employee recognition programs.
  • Referral bonus opportunities.

About Us

Pyramid Healthcare Inc. is a diverse workforce that values integrity, dedication, collaboration, and passion. We strive to improve lives and support our mission through exceptional care and support.



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