Insurance Case Manager Jobs in California (NOW HIRING)

At Houston Methodist, the Case Management (CM) Coordinator position is a proficient CM representative that provides technical, clerical and data management support to the case management and social work department staff to facilitate efficient utilization of resources and discharge planning. This position performs the duties and responsibilities of a CM Representative, in addition to a wide variety of duties of a higher complexity in support of Case Management operations including referrals management, collaboration with post-acute care providers, access to agencies and other community resources and transportation. In addition, the CM Coordinator position anticipates independent actions necessary to provide competent and professional assistance to meet the needs of social workers/case managers and patients. This position also coordinates, oversees, records and transmits information pertinent to the resource management of patients to next level of care providers. The CM Coordinator position serves as the mentor/preceptor to other CM representatives, resulting in the delivery of exceptional patient care and adherence to standards of practice for optimal patient safety, quality outcomes, and customer service. FLSA STATUS
Non-exempt
QUALIFICATIONS
EDUCATION

• Associate's degree or two additional years of experience in lieu of degree

EXPERIENCE

• Five years experience in service recovery, insurance, case management, or business office-related area, three of which must be in case management
• Previous experience in Case Management, post-acute setting or physician practice

SKILLS AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
• Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
• Strong knowledge of community resources
• Ability to work independently while collaborating with other team members and exercise sound judgment in interactions with physicians, payors, and patients and their families
• Adapts to multiple ongoing priorities with minimal supervision including but not limited to organizing workflows and actively participating in problem-solving
• Demonstrates ability to access information both in the department and within the hospital system to support the department and interprofessional health care team as appropriate
• Possesses expert computer knowledge including electronic health records, i.e., Epic, Microsoft Office (Word, PowerPoint, & Excel) to maintain patient information
• Strong knowledge of Medical Terminology
• Excellent telephone, oral and written communication skills, time management and prioritization skills
• Must be able to learn new skills effectively

ESSENTIAL FUNCTIONS
PEOPLE ESSENTIAL FUNCTIONS

• Role models as a preceptor and implements staff education specific to patient populations and unit processes; coaches and mentors other staff. Functions a resource for case management and social work resources and needs for the department and the hospital. Exemplifies/leads teamwork by responding positively to requests for assistance. Fosters staff engagement by demonstrating active listening, requesting and acknowledging feedback, making equitable decisions, providing rationale when appropriate, and supporting organizational.
• Arranges, expedites and completes acquisition of post-acute care needs or secures insurance authorization, as directed, confirming with social workers and case managers, and ancillary departments, based on physician orders, payor/reimbursement practices and regulations that may impact the patient's plan of care.
• Facilitates designing and redesigning of CM representative processes and workflow. Actively participates in making recommendations for improving working relationships in the department, hospital, vendors, and post-acute providers. Leads contributions with leadership to identify workflow opportunities, assisting with recruitment and retention efforts, including to improve employee engagement department scores for CM representatives through peer-to-peer accountability.

SERVICE ESSENTIAL FUNCTIONS

• Provides necessary transfer/admission documentation. Reviews for accuracy and completion. Supports clerical and clinical functions for patients, physicians and staff. Provides administrative assistance, as needed, including scheduling follow-up appointments or providing clinical updates to payors, as needed Initiates efficiency initiatives for durable medical delivery process.
• Provides front-line problem resolution to straightforward questions or customer service needs. Provides guidance to payors/ancillary partners and/or CM Representatives on service standards and service recovery. Partners with leadership to implement best practices to deliver unparalleled service.
• Tracks and trends service failures. Articulates and takes action for service gaps to leadership and along with recommendations for improvement. Collaborates with the leadership team to develop strategies to maximize efficiency and remove barriers to ensure effectiveness of post-acute care referrals or minimize denials or delays.
• Participates in action plans for transition of care/discharge questions for patient satisfaction. Identifies opportunities to improve the customer experience. Contributes towards improving department scores for patient satisfaction on unit-based scorecard through peer-to-peer accountability.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Serves as a role models for situational awareness, using teachable moments to improve safety. Contributes to identification of corrective action and improvement activities to meet department and hospital targets for quality and safety, collaborating with the interprofessional health care team.
• Collaborates with the leadership team to develop opportunities to improve documentation of insurance correspondence and compliance with payors/appeals, distribution of regulatory notices, including the CMS Important Message from Medicare, Medicare Outpatient Observation Notice, etc.

FINANCE ESSENTIAL FUNCTIONS

• Proactively secures reimbursement/certification and authorization-related needs, independently and escalates to management if needed. Documents approvals and authorization numbers from payors. Logs communications and provides information to social workers and case managers, business office/patient access, etc. on insurance/managed care benefits and post-acute care needs.
• Streamlines concurrent insurance denials and/or appeals process, in collaboration with management and nursing staff. Develops and implements best practices to ensure timely and accurate EMR documentation of authorization, approvals, and denials and recommends strategies for improvement.
• Identifies trends by payor and reports findings to management for further. Provides information to patients/families on insurance/managed care benefits and assesses need for further education by social worker/case manager.
• Self-motivated to independently manage time effectively and prioritize daily tasks. Provides input into the department resource utilization including capital and operational budget needs as appropriate. Collaborates with the leadership team to determine cost-reduction strategies. Contributes towards department financial targets through timely documentation, minimizing incidental overtime, optimizing efficiency and other areas according to department specifications.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Shares knowledge with CM Representatives of payor/reimbursement practices and regulations that may impact patient's plan of care and confers with care coordinators and social workers to prioritize placement requests.
• Offers innovative solutions through participation in department projects and shared governance activities. Ensures own career discussions occur with appropriate management. Completes and updates the My Development Plan on an on-going basis.

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE
• Uniform: No
• Scrubs: No
• Business professional: Yes
• Other (department approved): No

ON-CALL*
*Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below.
• On Call* No

TRAVEL**
**Travel specifications may vary by department**
• May require travel within the Houston Metropolitan area No
• May require travel outside Houston Metropolitan area No

Work Shift:

1 - Day (United States of America)

Job Category:

Non-clinical Houston Methodist Cypress Hospital, Houston Methodist's eighth hospital, opened in the first quarter of 2025 in a prime location in the heart of the rapidly growing U.S. 290 corridor. It incorporates the most advanced technology available, featuring innovations designed to enhance communication between patients, physicians, staff and families. The facility combines state-of-the-art technology with world-class clinicians, creating an unparalleled experience for patients, employees and physicians.

Houston Methodist is an Equal Opportunity Employer.