TECH, CASE MGMT-OH

To analyze and process internal, external, transfer requests and provide and obtain authorization or denial by working with Occupational Health (OH) guidelines, the OH Chief Physician and the insurer.  To pre-certify MCO surgery requests and provide and obtain authorization or denial by working with OH guidelines, the OH Chief Physician and the insurer.  To document accurately to comply with billing requirements.  To provide communication to the insurer, physician, vendors and patients, and facilitate scheduling.  To provide support to the Nurse Case Managers.

• Facilitates compliance with Workers Compensation Division 15 rules by conducting review of medical record for surgical medical necessity based on established protocol/screening criteria. Abstracts and interprets medical documentation as it relates to diagnosis & procedure, and analyzes for decision/action. Problem-solves related issues and makes initial determination to approve or triage the precertification. Provides/ensures high degree of accuracy and attention to detail in precertification review documentation.  Coordinates pre-certification review to MCO Medical Director whether referral is based on internal protocols or insurer request.  Facilitates MCO Medical Directors review. Monitors for review outcome and disseminates determination.  Ensures compliance with Division 15 rules by identifying second surgical opinion cases, facilitates/coordinates with MCO Medical Director and provides review support on a case by case basis.  Generates appropriate documents to communicate MCO Medical Directors decision to insurer, injured worker, and surgeon.  Prepares documentation for denial/disapproval of procedure, service or device.  Assigns length of stay (LOS) for all inpatient admissions.  Identifies/triages injured workers to Case Managers and OH Service Center for additional services and/or follow-up.
• Coordinates and conducts surgery notification and pre-authorization process for the OH Department. Works within defined timeframe with specialty service nursing and doctors to obtain pertinent data required by state and federal regulated agencies. Verifies and assigns correct ICD-9, ICD-10 and CPT coding for proper reimbursement.  Also obtains pre-authorization for certain other assigned procedures (ex. MRIs, hearing aids, retroactive surgical).  Research and verify claim and membership status, contacting and coordinating appointment between injured worker and non- plan medical provider. Coordinate record gathering, claim information and approve scheduling.  Contact MCO Medical Director to arrange second-level review.  Contact internal and external customers to obtain or provide information which assists in determining medical necessity and/or surgery authorizations.  Work with specialty services nursing, OH nursing, and physicians on daily basis.  Identifies areas for administrative review.  Identify cases and direct them to area case managers.
• Coordinate/manage external specialty referrals for: Work Hardening and Conditioning Programs, Pain Program, Brain Injury Rehabilitation Consultation (BIRC), and Physical Capacity Evaluations (PCE) for the OH Department, alternative care (acupuncture, chiropractic), and mental health.  Works with providers, injured workers, and external vendors to facilitate appointment, approval and record transfer.
• Coordinates, maintains, updates and distributes external contract specialty vendor lists for department. Maintains contract dataset in claims tracking system.
• Maintains a monthly precertification log and reports. Monitors precertification process and identifies/implements operational changes which promote efficiency and accuracy. Develops ongoing policies and procedures for precertification program and surgery notification/authorization process including written communication plans, forms, or program letters.
• Analyze and process referral requests for OH patients to non-plan specialty services.  Obtain necessary approval from department Chief, or MCO director including exceptions to department protocols.  Verify status of contract provider, verify diagnosis, date of injury, employer/insurer. Notify insurer.  Obtain current claim status and insurer information and/or insurer approval if necessary. Verify authorization for service. Coordinate patient care with non-Plan providers. Document in Claims Tracking system/KOJUR.  Verify and track external provider treatment plans and extension requests.  Provide billing information to the providers as well as assist non plan providers with benefit and contractual information.  Assist with denied service issues.  Maintain and continuously demonstrate general knowledge of workers compensation rules and regulations for Oregon, Washington and Federal workers compensation benefit systems. Ensure state and federal regulatory and contract compliance.  Research and verify claim and membership status, contacting and coordinating appointment between injured worker and non- plan medical provider. Coordinate record gathering, claim information and approve scheduling.  Coordinate referrals into the Kaiser systems for injured workers who have received treatment at non plan providers and wish to transfer care to Kaiser OH.  Contact injured worker and verify claim information, claim status and eligibility for transfer.  Coordinate medical record transfer, communicate approval for scheduling and provide claim and medical record information to Kaiser OH providers for review prior to treatment.  Send information to advice nurse for triage and approval by the MCO Director, Chief Physician or designated physician.  Obtain authorizations needed to secure payment for assigned procedures. (ex. MRI, ESI, DME).  Maintain KOJUR database of contracted providers and CHP providers for MCO Provider List.  Perform administrative case management support to the nurse case managers.  Perform other duties as assigned.