Marquis Health Services

Managed Care Specialist

US-NJ-Mount Laurel
ID
2017-2016
# of Openings
1
Category
Management
Laurel Brook Rehabilitation and Healthcare Center

Overview

MARQUIS HEALTH SERVICES  - MOUNT LAUREL, NJ

 

Laurel Brook Rehabilitation and Healthcare Center is hiring a Managed Care Specialist. The Managed Care Specialist provides direct oversight to facility care navigators and external case managers/ clinical liaisons to support the delivery of effective and efficient patient care. Oversees utilization management and transition management for patients within the assigned caseload. Partners with Social Workers, Care Navigators, and external case managers/ clinical liaisons and collaborates with other health care team members to identify appropriate utilization of resources and to ensure reimbursement.

 

Marquis Health Services is one of the Northeast's leading providers in Subacute Rehabilitation & Skilled Nursing Facilities. As the healthcare subsidiary of the three-generation family-owned organization, Tryko Partners, Marquis Health Services has been helping patients live the best possible lives within their facilities through a wide-range of exceptional rehabilitative services.

 

We offer competitive wages, a comprehensive benefits package and in-house advancement opportunities through our continuous education and training opportunities. P

Qualifications

  • Bachelor’s degree in Business or Health Management, advanced degree preferred
  • Minimum of 5 years of extensive, direct experience in contract negotiation
  • 5 years direct operational experience in a multiple site outpatient facility setting including profit and loss responsibility
  • 3 years direct supervisory experience
  • Ability to manage databases and provide analysis

 

Responsibilities

  • Responds to inquiry calls from hospital discharge planners, families, facilities, and other referral sources. Manages the admission process by maintaining updated bed availability and facility services information at all times. Manages the inquiry process professionally, timely and with appropriate follow-up. Effectively manages occupancy levels and census/premium mix enhancement. Must be able to multi-task.
  • Develops and maintains relationships to advise referral sources of bed availability and new product and services. And efficiently meets and daily needs of the community at large. Maintains current database of existing and potential referral sources.
  • Alerts appropriate department heads and building staff of projected changes, i.e. admissions, bed changes, and discharges, via phone, to discuss forthcoming changes. Utilizes bed management principles. Maintains a close working relationship with the Director of Nursing (DNS) and the Business Office Account Manger to assure appropriate and efficient decisions about prospective admissions. Recommends admission decisions to facility management.
  • When admissions determinations are made, communicates with facility staff to initiate appropriate room and bed selection.
  • Communicates special needs of new admits to staff to ensure a smooth transition. Ensures daily that referral sources and admissions data are entered into the automated referral system.
  • Manages multiple inquiries and presents referral to appropriate facilities based on location and services provided.
  • Maintains a working knowledge of Federal and State regulations and reimbursement guidelines (Medicare and Medicaid). Verifies managed care referrals and negotiates initial rate and communicates to facility.
  • Monitors and evaluates customer satisfaction. Audiences might include referral sources, new admissions, post discharges, current residents and families (via Corporate Family Survey), community sources and inquires that were unable to admit. Shares results with the management team, PI committee, and others as appropriate to develop action plans, as needed.
  • Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third party information. Intervenes when determinations are not in alignment with clinical information, clinical criteria or third party information to resolve the situation. 
  • Collaborates with the third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial.  Intervenes to prevent the denial where possible. Supports the effective prevention and management of denials, including drafting appeal letters and/or providing information as part of the appeal process.
  • Develops and maintains a unique patient specific care management plan with mutually agreed upon goals in collaboration with the facility care navigator/ rehab manger, IDT team, and patient/family and treatment team; identifies gaps in care and barriers to care.
  • Direct organization’s activities of strategic planning, evaluation, coordination, and implementation of various managed health care programs, (HMOs, PPOs, POS, etc.)
  • Oversee Division’s contractual relationships with managed care organizations and other third party payors regarding rate structures for services, clinical and financial reporting obligations.
  • Develops and directs regional marketing efforts to third party payors in order to support growth and profitability in the region.
  • Recommends and develops policies and procedures for various activities to assure objectives of managed care organizations and patients are met.
  • Ensures that all facilities meet and maintain appropriate credentialing requirements and licenses.
  • Responsible for implementation and achievement of business plan, budget, and key performance indicators and communication to senior leadership
  • Responsible for negotiating and implementing contracts with payers that require clinical and quality outcomes measurements
  • Assist with designing Quality Improvement Projects that will improve outcomes in facilities that are not meeting goals
  • Responsible for the development and implementation of a regional marketing plan to support regional growth and profitability and marketing of services to third party payors.
  • Keeps all patient information confidential.
  • Manages multiple tasks and prioritizes accordingly.

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