Position Purpose:
Supports administrative care management activities including performing outreach, answering inbound calls, and scheduling services. Serves as a point of contact to members, providers, and staff to resolve issues and documents member records in accordance with current state and regulatory guidelines.
Education/Experience:
Requires a High School diploma or GED
Requires 1 – 2 years of related experience
License/Certification:
For Florida-Sunshine Health Plan - All interactions with members are done telephonically
Provides outreach to members via phone to support with care plan next steps, community or health plan resources, questions or concerns related to scheduling and ongoing education for both the member and provider throughout care/service
Provides support to members to connect them to other health plan and community resources to ensure they are receiving high-quality customer care/service
May apply working knowledge of assigned health plan(s) activities and resources
Serves as the front-line support on various member and/or provider inquiries, requests, or concerns which may include explaining care plan procedures, and protocols
Supports member onboarding and day-to-day administrative duties including sending out welcome letters, related correspondence, and program educational materials to assist in the facilitation of a successful member/provider relationship
Documents and maintains non-clinical member records to ensure standards of practice and policies are in accordance with state and regulatory requirements and provide to providers as needed
Knowledge of existing benefits and resources locally and make referrals to address Social Determinants of Health (SDOH) needs
Performs other duties as assigned
Complies with all policies and standards
EEO:
“Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”
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Provides outreach to members via phone to support with care plan next steps, community or health plan resources, questions or concerns related to scheduling and ongoing education for both the member and provider throughout care/service
Provides support to members to connect them to other health plan and community resources to ensure they are receiving high-quality customer care/service
May apply working knowledge of assigned health plan(s) activities and resources
Serves as the front-line support on various member and/or provider inquiries, requests, or concerns which may include explaining care plan procedures, and protocols
Supports member onboarding and day-to-day administrative duties including sending out welcome letters, related correspondence, and program educational materials to assist in the facilitation of a successful member/provider relationship
Documents and maintains non-clinical member records to ensure standards of practice and policies are in accordance with state and regulatory requirements and provide to providers as needed
Knowledge of existing benefits and resources locally and make referrals to address Social Determinants of Health (SDOH) needs
Performs other duties as assigned
Complies with all policies and standards
Manager updates- Position primarily serves as the communication link between SHP and guardians/community providers regarding PRTF level of care.
Story Behind the Need
- What is the purpose of this team?
- What is driving this need? (ex. Backfill for FTE or CW, new project, business growth)
- Describe the surrounding team (team culture, work environment, etc.) & key projects.
- Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?
Responsible for accurately tracking and documenting updates and efforts to retrieve updates in the PRTF PAR/CBST and PRTF Admissions/Discharge process so would be helpful for candidate to have some knowledge of the Psychiatric Residential Treatment Facility process in Kansas. The Kansas PRTF Process is drastically different from other prior authorization request processes and requires someone who is attentive to details and well organized to be able to track multiple requests/cases and provide appropriate follow-up to support completion by external and internal partners within short time frames.
This position is open currently as temporarily needing coverage for the team member previously filling this role who is out on an undetermined amount of leave and uncertainty whether she will be able to return to this position due to ongoing health issues.
This position works closely with the PRTF Liaison/PRTF Senior Care manager and the PRTF Manager as well as 4 SHP PRTF Care Managers that are assigned specifically to the 9 Kansas PRTFs in the State in order to facilitate access to PRTF level of care when appropriate and transition to and discharge from PRTF. This position is also primarily responsible for the upkeep/updates for a State created report weekly to KDADs that tracks and provides updates on member’s requesting/approved/admitting/discharging from PRTF level of care.
Typical Day in the Role
- Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD).
- What are performance expectations/metrics?
- What makes this role unique?
Typical days include working closely with PRTF Senior Care manager, Manager, and PRTF CM teams to coordinate and communicate regarding PRTF level of Care Requests, approvals/denials, and communication directly with Guardians and Community Providers.
Performance metrics include accurate and timely updates for the KDADs PRTF Waitlist report as well as successfully meeting deadlines and TATs for PRTF requests, 6o day reviews, admissions etc.
This role is the only non-master’s level position on the PRTF CM team and serves to ensure effective and accurate information is shared with appropriate internal and external contacts as well as being responsible for the primary data report shared with KDADs/state.
Candidate Requirements
Education/Certification
Required: High School diploma
Preferred: Bachelor’s degree in Behavioral health related fields (SW, Psychology, etc)
Licensure
Required: No licensure required.
Preferred:NA
Years of experience required: Technically no years of experience are required though would be helpful to have any level of experience with MCO/Insurance related activities or specific knowledge of the PRTF process.
Disqualifiers: None identified.
Additional qualities to look for: Organized, self-driven/motivated, attention to detail.
- Top 3 must-have hard skills stack-ranked by importance
1
Computer literacy- especially with Excel, outlook, Electronic Health Records.
2
Ability to work in a fast paced environment with ability to track on-going requests/needs while being able to quickly shift to additional requests etc.
3
Organized and detailed.
Candidate Review & Selection
- Shortlisting process
- Candidate review & selection
- Interview information
- Onboard process and expectations
Projected Manager Candidate Review Date:
1-2 days post shortlisting (for your reference) :ASAP
Type of Interviews:
Teams/Zoom interviews preferred after initial screening.
Required Testing or Assessment (by Vendor):
NA.
