Maria Guzman

• Promotes optimal use of health care resources by assisting clinical staff with the administrative functions involving case management; processing and/or reviewing inpatient admissions under clinical supervision according to departmental guidelines; assisting in the monitoring and evaluating process of Utilization Management Program, and responding to internal and external customer telephone inquiries.
• Works closely with all departments necessary to ensure that the processes, programs, and services are accomplished in a timely and efficient manner in accordance with companies policies and procedures and in compliance with applicable state and federal regulations including CMS, DHCS, and/or Medicare Part D.

· Coordinate the following activities for CHG members admitted to hospital: Request review from Case Manager; gather all clinical documentation from case management review, fax to appropriate facilities, and keep track of information faxed.

· Request clinical information for Children’s Hospital admissions via Chart Max, as required by the Case Manager.

· Process inpatient denial letters and ensure appropriate denial language is incorporated.

· Run the daily Inpatient Census and email to appropriate staff by 10:00 a.m. every morning.

· Contact skilled nursing facilities, tertiary care units, and acute rehabilitation centers to verify if a member is still inpatient and ascertain the level of care. If a member has been discharged, report to the appropriate Case Manager and enter authorization information in QNXT once the level of care has been determined by the Case Manager.

· Coordinate any requests for home health or durable medical equipment as a result of discharge from hospital, skilled nursing facility, or acute rehabilitation center and on call issued field authorizations. Enter authorization information in QNXT.

· Provide administrative support to the Case Management team, including telephone coverage.

· Provide phone coverage for Case Management Clerk when out of the office.

· Contact hospitals to verify if a member is still inpatient. If the member has been discharged, process discharge letters and report information to the Case Manager. Upon review by the Case Manager, enter the discharge information, including the level of care and status (P09 and D26) in QNXT.

· Provide authorization information, including the level of care, to hospitals as requested.

· Verify CCS cases with Preventive Services Unit.

· Enter information for provider appeals reviewed by Case Manager on Provider Appeals spreadsheet and update authorization information (e.g. denial upheld, additional days approved, modified level of care) in QNXT, when appropriate.

· Maintain long term care (LTC) assessment log to ensure new members are logged in and timely notification to LTC vendor to complete required assessments

· Track turn-around time to ensure LTC assessments are completed by LTC vendor within (3) business days

· Ensure completed assessments are sent back to CHG for the Case Manager review. Maintain assessments in appropriate folders and forward HRA to HRCM department.

· Authorize LTC admissions per The Case Manager's prescribed duration or issue a denial notification as dictated by the medical director.

· Timely processing and data entering of skilled nursing facility extensions as indicated.