Working with all three hospitals, obtain all authorizations for SNF care, both by utilizing the NaviHealth portal for the payers who utilize that system as well as any other processes used by all other managed care plans.
Establish pathways to ensure we are meeting the payer's expectations for submissions and ensuring these pathways are kept current. For Managed Medicaid payer authorization processes, there will be a similar system utilized by the State to approve all post-acute care (including Home Health) for Medicaid beneficiaries covered by the Pre-Paid Health (commercial) Plans.
Responsible for understanding expected clinical components for authorization justification and will work independently to ensure all components are included on the initial submission.
Autonomy to contact the needed member of the multidisciplinary team, including providers. If the payer denies the service, this employee will reach out to the provider and/or case manager to discuss clinical rationale for denial and work in collaboration with them to mitigate the denial
Assist with placements for long stay/complex patients by following up on referrals made and/or searching out-of-state resources for placement, including assessing individual facility's clinical capabilities to provide appropriate care for individual patients; monitor/follow patients on the daily SNF admission report to obtain post-acute authorization prior to their return to the SNF; and maintain up-to-date post-acute provider contact list to ensure we have the correct contact names/numbers.
Work collaboratively with the Physician Advisors (PAs) to establish a program for managing peer-to-peer reviews for Physician Advisors (PAs), to include denials for post-acute level of care services. Meticulous record keeping of this process will be expected as data will be needed to assess volume for future expansion.
Graduation from a Bachelor's Degree program, Social Work or Health Care related field highly preferred. 1 year of work experience – upaid or paid internships count toward experience
Knowledge, Skills and Abilities
This position requires an understanding of medical terminology; excellent organizational, technical and problem solving skills; excellent written and verbal communication skills, and demonstrated ability to navigate in an electronic medical record (Epic preferred).
Job Code: 00004125 PROGRAM SPECIALIST Job Level: D2
Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secureand welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
As a world-class academic and health care system, Duke Health strives to transform medicine and health locally and globally through innovative scientific research, rapid translation of breakthrough discoveries, educating future clinical and scientific leaders, advocating and practicing evidence-based medicine to improve community health, and leading efforts to eliminate health inequalities.