RESPONSIBILITIES:

• The Case Management Authorization Specialist IP (CMAS) has a general understanding of insurance requirements as it relates to insurance verification, notification, authorization and collaboration.
• This role functions with minimal oversight and guidance in the Care Management Inpatient Department or Utilization Management Department with distinct responsibilities.
• Primary duties and responsibilities: Care Management Inpatient Department: 1. Assists the Care Management Inpatient team to timely transition patients into post-acute services within the allotted amount of reimbursable hospital days, as determined by the clinical authorization obtained. 2. Submits referrals for securing post-acute care services as directed, which may include Home Health, Durable Medical Equipment, Subacute Rehabilitation, Inpatient Rehabilitation Facility, Long-Term Acute Care, Hospice, or Long-Term Care. 3. Prioritizes work with minimal guidance for optimal reimbursement and to avoid financial risk to both patient and hospital. 4. Ensures proper use of Care Management Systems and display adherence with workflows, which guide all responsibilities.
• Utilization Management Department: 1. Verify insurance eligibility and submit notice of admission (NOA) for inpatient and observation admissions to the identified primary and secondary insurances based on the payer's notification requirements and UR Department processes. 2. Verify completion of automated NOAs for appropriate insurances, and if necessary, will resubmit manually. 3. Submit appropriate admission and continued stay clinical documentation supporting services or care provided to insurances without access to Emory's Electronic Health Record based on payer's preferred method and reimbursement methodology. 4. Secures reimbursement by confirming insurance authorization determination for the inpatient or observation admission through appropriate and required communication methods. 5. Will add approved bed days to Emory's Electronic Health Record as appropriate based on authorization and reconcile authorized versus actual days to secure reimbursement for provided care. 6. Prioritizes work with minimal guidance for optimal reimbursement and to avoid financial risk to both patient and hospital. 7. Display adherence with department processes, which guide all responsibilities.
• Compliance: Care Management Inpatient Department: 1. Ensure regulatory requirements are met as it relates to the delivery of Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), Medicare Change of Status Notice (MCSN), and Medicare Hospital Issued Notices of Non-Coverage (HINNs) for Medicare beneficiaries as appropriate. 2. Maintains all required annual competencies, metrics, and fully participate and engage in department process improvements.
• Utilization Management: 1. Follow the UR Department¿s peer-to-peer workflow as appropriate. 2. Will inform the Patient Access Department and UM leadership of any discrepancies identified related to coordination of benefits and/or coverage as it relates to ineligible coverage, non-covered services or out of network status. 3. Assists in collaborative efforts with the Care Management Department, Revenue Cycle, Utilization Review Medical Directors, and other required departments. 
  
  

Minimum Qualifications:

• Education - High School diploma or equivalent.
• Experience - At least two years of experience in a healthcare setting is required.
• Preferred Qualifications: Education - Associate or Bachelor's degree preferred.
• Experience - Two years of insurance verification, authorization, or related work preferred.
  
  
  

Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law.

Emory Healthcare is committed to providing reasonable accommodations to qualified individuals with disabilities upon request. Please contact Emory Healthcare’s Human Resources at careers@emoryhealthcare.org. Please note that one week's advance notice is preferred.