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Job Overview

The Care Management Specialist is responsible for establishing and maintaining relationships with providers, patients, families and vendors of Fairview Partners, as well as serving as the liaison between Fairview Partners and the health plans for all community enrolled members. The Care Management Specialist directly supports Fairview Partners Care Coordinators.

Responsibilities:

Serve as a liaison to patients, vendors, providers, and health plan representatives to resolve issues related to billing and health plan referral verification:

+ Understands the guidelines and processes within each health plan surrounding claims payment for patient referrals.

+ Assists case managers or providers with utilization, authorization, and claims payment as appropriate and requested.

+ Coordinates and facilitates services as directed by the Care Coordinator.

Performs, understands, and can explain functions related to the referral process of patients:

+ Approves/Directs patient referrals to appropriate setting.

+ Understands benefit structure of each contracted health plan.

+ Communicates directly with vendors, clinics and payers or as needed to patients.

Responsible for oversight of monthly member reporting:

+ Reviews health plan member reports for accuracy which ties to monthly capitation payments from health plans.

+ Works with the health plans and care coordinators to correct discrepancies and appropriately assigns members to correct care system.

+ Utilizes Excel and Access database to report new member information to providers and internal entities of Fairview.

Coordination of Member Care:

+ Assists the Care Coordinators in coordinating and ordering services for community members. This includes working with various home care agencies and community agencies to assure the appropriate services have been scheduled.

+ Researches community resources for Fairview Partners members and develops relationships with new vendors to utilize their services on an on-going basis.

+ Documents member information using EPIC and the Department of Human Services reporting system.

+ Monitors and processes changes to member’s health plan status, agency updates, and other internal tracking spreadsheets.

+ Assists members in transportation, appointment, and DME & supply requests.

Required Qualifications

+ Two-year degree in a healthcare-related field

+ 4 years in a health care setting

+ 2 years recent experience in a health care setting

+ 2 years recent experience with Microsoft Word, Excel, and Access.

+ Knowledge of third-party payers, billing procedures and insurance

+ Ability to work independently and exercise independent judgment

Preferred Qualifications

+ 4 years experience in a health care setting

+ 3 years experience with EPIC, Microsoft Word, Excel, and Access.

+ Previous experience with referrals processing in medical office.

Benefit Overview

Fairview offers a generous benefit package including but not limited to medical, dental, vision plans, life insurance, short-term and long-term disability insurance, PTO and Sick and Safe Time, tuition reimbursement, retirement, early access to earned wages, and more! Please follow this link for additional information: https://www..fairview.org/careers/benefits/noncontract

Compensation Disclaimer

An individual's pay rate within the posted range may be determined by various factors, including skills, knowledge, relevant education, experience, and market conditions. Additionally, our organization prioritizes pay equity and considers internal team equity when making any offer. Hiring at the maximum of the range is not typical.

EEO Statement

EEO/Vet/Disabled: All qualified applicants will receive consideration without regard to any lawfully protected status