Sutter Health Case Management Representative - Case Management (Full Time - Days) in Sacramento, California
The Case Management Representative demonstrates an ability to read, comprehend and understand complex medical guidelines to determine if appropriate medical information has been provided for authorization and referral requests and demonstrates understanding of client's and payer’s responsibility and obligations for payment. Performs authorization and benefit management functions by reviewing referral requests for appropriateness and by obtaining and/or providing authorization. The Case Management Representative role includes, but is not limited to authorization review for acute, ambulatory and out of network cases, Medical Director case review, client/member customer service, database entry, maintenance and auditing, preparation of statistical reports, and assistance with special projects as assigned while maintaining confidentiality of information. Other routine functions include member eligibility, routine referral and authorizations data entry processing.
Education:Requires a High School Diploma or equivalent. AA degree and/or equivalent work experience in HMO related managed care environment
or health-related field preferred.
Experience:Experience with reading, comprehending and understanding complex medical guidelines. Experience and ability to maintain federal and state regulatory requirements including NCQA, CMS/HCFA, and DMHC.
Knowledge:Knowledge of Microsoft Word, Access, Excel, and PowerPoint. Medical Terminology, ICD-9 and CPT codes desired. Ability to accurately interpret contractual and financial payer risk information.
Organization: *Sutter Valley Hospital
Title: Case Management Representative - Case Management (Full Time - Days)
Location: California-Greater Sacramento Area-Sacramento
Requisition ID: SVH-1720083
All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, marital status, sexual orientation, registered domestic partner status, sex, gender, gender identity or expression, ancestry, national origin (including possession of a driver's license issued to individuals who did not present proof of authorized presence in the U.S.), age, medical condition, physical or mental disability, military or protected veteran status, political affiliation, pregnancy or perceived pregnancy, childbirth, breastfeeding or related medical condition, genetic information or any other characteristic made unlawful by local, state, or federal law, ordinance or regulation. External hires must pass a background check/drug screening. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state, and local laws, including but not limited to the San Francisco Fair Chance Ordinance.