Outpatient Case Manager
Health Partners of Philadelphia (Philadelphia, Pennsylvania)

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HEALTH PARTNERS is the Philadelphia area’s only health plan that’s owned by a partnership of local hospitals and health systems.  We continually strive to improve the health outcomes of our members, building a healthier community in the process. Our corporate commitment to operate with respect and dignity in all relationships stands behind everything we do.  We offer excellent benefits, competitive salaries and a great 401(k) Plan.

GENERAL DESCRIPTION:  Assure cost effective, quality patient care management for DME, homecare, transportation and outpatient rehab services (includes but not limited to shift care, waiver programs, homecare, home infusion, hospice and occupational therapy, speech therapy and physical therapy).

KEY REQUIREMENTS:  Current Pennsylvania State RN or LPN license.  2+ years clinical nursing experience. Homecare and outpatient rehab services experience preferred.  Experience working in managed care environment preferred.  Experience with Medicare/Medicaid populations a plus.  Knowledge of medical necessity principles, including clinical criteria and knowledge of InterQual.  Computer literacy, including familiarity with Windows and Microsoft Office programs.  Ability to work independently.  Ability to work efficiently, with excellent time management skills.  Excellent communication skills both verbal and written.  Ability to work well with all types of providers/members.  Ability to maintain professional demeanor and confidentiality.  Sensitivity to the needs of every individual to be treated with respect and fairness.  Bilingual (preferred).  Requires sitting, standing, walking while reviewing documents or working with staff. Requires speaking by phone with providers, and members.  Requires working throughout the facility, carrying out assignments unassisted. Requires lifting or carrying of medical records up to 10 lbs. Regular and punctual attendance is a condition of employment.

PRIMARY RESPONSIBILITIES: Process/review requests (primarily faxes) for durable medical equipment (DME), homecare, hospice, transportation and outpatient rehab services such as occupational therapy, physical therapy and speech therapy.   Evaluate and authorize select homecare, DME services and outpatient rehab services for proper medical management and cost effectiveness.  Within scope of required education and training, provide clinical review for appropriateness of care.  Utilization of InterQual criteria and Health Partners Criteria will be source of review and standard for prior authorization.  Coordinate with discharge planning, UM, SNU to facilitate timely approval and coordination of services.  Provide ongoing case management with a focus on preventing admissions and ER visits.  Provide written and oral communication to members and providers for approvals/denial of services.  Select and complete with appropriate language letters to providers and members.  Track assigned cases for timely reviews/updates and ensure decisions are reflected in case documentation.  Identify duplication of services and opportunities for improvement.  Function as a liaison between ancillary providers and members.  Provide telephone service in a prompt and courteous manner.  Consults with Medical Directors for medical director review and medical necessity determinations.  Meet specified timeframes established by regulators (DPW, DOH, and CMS).  Identify expanded services, continuity of care services and track them for transition of care.  Accurately code all services using appropriate, ICD-9, CPT, and HCPCS coding systems.  Serves as liaison to customer service representatives, grievance & appeals staff, and other internal staff departments.  Assists and supports all related processes, including development of policies and procedures and process improvement efforts as assigned.  Participate in on-call program.