- Full Time/Contract
- Member Services
- Rancho Cucamonga, CA
Care Management Coordinator
Under the general supervision of the Care Management (CM) Manager and direct supervision of the CM Coordinator Supervisor, the CM Coordinator is responsible for advocating, facilitating and supporting care management activities
- Responsible for assisting Members with care coordination in respect to referral process such IPA for Durable Medical Equipment (DME), home health, and Specialist needs.
- Responsible for assisting with the referral process by contacting providers by phone, fax or email to request additional medical information as needed.
- Responsible for assisting the Care Managers in the management and coordination of care of Member identified with care management conditions
- Responsible for facilitating Member care to ensure that a continuity of care letter of agreement (LOA) is executed when appropriate.
- Collaborates on Member's care issues with other team members and consults with NCM or CM supervisor to ensure that appropriate treatment plan is followed, thoroughly and promptly.
- Responsible for processing and coordinating divorces, disenrollment, transportations, and language interpretation as needed and applicable.
- Assists with contact calls for monthly HRA pull, i.e. Complex Case Management and assisting with coordinating the members overall care as needed.
- Responsible for identifying HEDIS gaps and contacting the member to address these gaps.
- Responsible for covering Cisco ACD Queue telephone lines Phone queue.
- Assists with the coordination of access issues with PCP offices, specialists, radiology services and ancillary services such as PT, OT, speech therapies.
- Ensures documentations is accurate and in compliance with regulatory requirements and accreditation standards.
- Consults with assigned nurses for clinical assessment and decision prior to taking action that are clinical in nature.
- Performs any other duties as assigned or required to ensure Health Plan operations are successful.
- Participates in Medical Services staff meetings or other activities as needed
- Ensures the privacy and security of PHI (Protected Health Information) as outlined in Company's policies and procedures relating to HIPAA compliance including attending annual compliance training.
- Promotes a positive and collaborative working environment within the CM Team.
- Two (2) years customer service experience in medical clinics, hospitals, or IPAs. Managed care setting experience preferred. Knowledge of Utilization Management including referral process, ICD-10 and CPT codes preferred.
- Knowledge of utilization management process and care coordination in HMO or managed care setting. Knowledge of Medi-Cal, and Medicare managed care. Bilingual (English/Spanish) preferred – excellent written and verbal communication and interpersonal skills, understanding of and sensitivity to multi-cultural community, strong organizational skills, typing 45 words per minute, proficient in Windows applications, telephone courtesy, high degree of patience, and experience in data entry. Team culture a must.
- High school diploma or GED