Care Management Specialist

M Health Fairview has an immediate opening for a Care Management Specialist at its Edina, MN location.

This is a 1.0 FTE (80 hours per two week pay period) opening. This is a hybrid role with both onsite and offsite (remote) work, generally two days per week onsite, 7AM - 5PM hours range, no weekends and no holidays, meaning great work life balance!

M Health Fairview offers a competitive benefits package including medical/dental, 401k/403b with employer match, tuition reimbursement, and PTO! For details, please visit our benefits page by clicking here!

The Care Management Specialist is responsible for establishing and maintaining relationships with providers, patients, families and vendors of Fairview Partners, as well as serving as the liaison between Fairview Partners and the health plans for all community enrolled members.  The Care Management Specialist directly supports Fairview Partners Care Coordinators.

Job Expectations:

• Serve as a liaison to patients, vendors, providers, and health plan representatives to resolve issues related to billing and health plan referral verification:
• Understands the guidelines and processes within each health plan surrounding claims payment for patient referrals.
• Assists case managers or providers with utilization, authorization, and claims payment as appropriate and requested.
• Coordinates and facilitates services as directed by the Care Coordinator.

• Performs, understands and can explain functions related to the referral process of patients:
• Approves/Directs patient referrals to appropriate setting.
• Understands benefit structure of each contracted health plan.
• Communicates directly with vendors, clinics and payers or as needed to patients.

• Responsible for oversight of monthly member reporting:
• Reviews health plan member reports for accuracy which ties to monthly capitation payments from health plans.
• Works with the health plans and care coordinators to correct discrepancies and appropriately assigns members to correct care system.
• Utilizes Excel and Access database to report new member information to providers and internal entities of Fairview.

• Coordination of Member Care:
• Assists the Care Coordinators in coordinating and ordering services for community members. This includes working with various home care agencies and community agencies to assure the appropriate services have been scheduled.
• Researches community resources for Fairview Partners members and develops relationships with new vendors in order to utilize their services on an on-going basis.
• Documents member information using EPIC and the Department of Human Services reporting system.
• Monitors and processes changes to member’s health plan status, agency updates, and other internal tracking spreadsheets.
• Assists members in transportation, appointment, and DME & supply requests.

Required

Education

Two year degree in a healthcare-related field, or minimum equivalent work experience of four years in a health care setting.

Experience

Two to four years of recent experience in a health care setting.

Two to three years of recent experience with Microsoft Word, Excel and Access.

Preferred

Experience

Four years of experience in a health care setting.

Three years of experience with EPIC, Microsoft Word, Excel and Access.

Previous experience with referrals processing in medical office.

Other Skills We Desire:

Knowledge of third party payers, billing procedures and insurance.

Ability to work independently and exercise independent judgment.

Excellent customer service, public relations and communication skills

Ability to prioritize and work with a fluctuation in workload while working independently

Ability to adapt to change and engage in ongoing process improvement

Flexibility to work at other sites is encouraged

We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, sex, gender, gender expression, sexual orientation, age, marital status, veteran status, or disability status. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation.