• Reimbursement - Clinical Case Manager

    Location US-MD-Columbia
    Job ID
    2018-1233
    # Openings
    1
    Category
    Reimbursement
  • Primary Purpose of Position

    The Clinical Case Manager will provide clinical and health policy expertise regarding payer coverage, and reimbursement. The Clinical Case Manager role is responsible to support the Reimbursement Hotline and be an advocate for patients to assist in securing coverage for Osiris Products. The ideal candidate will have an RN degree with 3+ years of clinical experience in a wound care center. The candidate must have comprehensive knowledge of reimbursement, coding, medical policies, treatment guidelines and billing for advanced wound therapies, including skin substitutes, in the HOPD and/or Physician office site(s) of care.  

    Principal Responsibilities

    • ESSENTIAL DUTIES AND RESPONSIBILITIES
    • Primary contact to handle Reimbursement Hotline clinical interactions with payers and be an advocate for patient coverage
    • Primary contact to discuss prior authorizations, exceptions and other escalated cases with payer Nurse Case Managers, Utilization Management, Medical Policy and other clinical discussions
    • Answer provider questions regarding clinical documentation, coding, treatment guidelines, prior authorizations and claim questions
    • Review patient chart notes for prior authorizations and pre-determinations to ensure clinical documentation and coding meet medical necessity and payer coverage criteria and guidelines
    • Collaborate with Market Access team to update payer policies, scripts, and coding requirements in the Hotline database; assist with updating Reimbursement Guides
    • Educate Hotline personnel, RAMs and Osiris representatives on clinical documentation, coding, and payer policy questions
    • Advise Hotline staff on clinical questions during benefits investigations
    • Conduct benefits investigations when necessary
    • Ability to manage time efficiently and prioritize job responsibilities
    • Provide clinical advice to Market Access, Marketing and Sales, especially topics related to reimbursement, policy and coverage
    • Assist with training of Hotline staff, market access and field sales
    • Provides exceptional customer service to internal and external customers; resolves any customer requests in a timely and accurate manner; escalates complaints accordingly.
    • Performs related duties as assigned.

    Qualifications

    QUALIFICATIONS To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

     

    Required: Registered Nurse, Wound Care Experience

    Preferred: BSN or MSN preferred; Reimbursement Experience.

    EDUCATION and/or EXPERIENCE

    1                 Wound Care experience

    2                 Knowledge of Medicare, Medicaid, and Private Insurer Reimbursement Methodology

    3                 Able to interpret and analyze detailed Medical policies

    4                 Basic understanding of the benefits investigation process [deductible, out of pocket, benefits exclusions, etc.]

    5                 Experience with the prior authorization process for products/services

    6                 Ability to communicate effectively both orally and in writing

    7                 Adept at handling sensitive and confidential situations

    8                 Ability to multi-task & adapt to changing priorities

    9                 Strong interpersonal skills

    10             Strong analytical skills

    11             Strong organizational skills; attention to detail

    12             Ability to resolve associate issues quickly and efficiently

    13             Ability to represent a positive and professional image

    14             Strong knowledge of Microsoft Word, Excel, Power Point and Outlook

     

    Osiris Therapeutics, Inc. is an Equal Opportunity Employer with a commitment to diversity. Applicants are considered on the basis of individual merit without regard to race, color, national or ethnic origin, gender, gender identity, sexual orientation, marital status, veteran status, pregnancy, age, religion, disability, genetic information, or any other characteristic protected by law.

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