Managed Care Coordinator

DIHS is seeking a motivated individual to assume the position of MCC to manage health care in a specialized population. The MCC preauthorizes detainee health care services utilizing a benefits package. The MCC directs, controls, and coordinates off-site and non-routine medical care all reimbursable medical, mental health, dental and durable medical equipment (DME) needs for individuals in the custody of the Immigration and Customs Enforcement (ICE).

Duties and Responsibilities:

• Receives written Treatment Authorization Requests (TARs) for reimbursable health care services from jail and health authorities, law enforcement officials, health care providers/institutions, ICE officials, and other designated individuals and organizations.
• Responds to requests for service authorization, first by establishing the eligibility of the potential recipient, for service utilizing ICE data systems and/or contacting ICE officials directly.
• Functions as first level reviewer to determine medical necessity and appropriateness of requested services by consulting the DIHS Medical and Dental Covered Services Plan and clinical guidelines established by the Chief Medical Director of the DIHS.
• Refers treatment authorization requests that do not meet criteria for approval, to the designated DIHS Medical Consultant or regional Dental Consultant for final review and determination.
• Informs TAR originator of all final determinations (via FAX or e-mail)
• Forwards all TARs (via FAX or e-mail) to the DIHS’ fiscal intermediary for claims processing and payment.
• Performs case management and utilization review on all hospitalizations processed through her/his office. Conducts concurrent utilization review at least every 72 hours on all hospitalizations, maintaining a record of all pertinent information (point of contact at the hospital with telephone number, patient identification and alien number, current and projected health status and discharge date projection).
• Reports all hospital admissions, continued stay, and discharge reviews to the DIHS Consultant Services Coordinator on a weekly basis utilizing standardized reporting forms.
• Submits monthly activity reports to the Chief, Managed Care Branch, through the Supervisory MCC, which include significant accomplishments, issues, problems, and workload activity.
• Provides support and assistance to ICE in placing detainees with special medical needs in appropriate facilities.
• Identifies prospective candidates for inclusion into the DIHS preferred provider network and communicates this information to the DIHS’ Contracting Officer.
• Conducts site visits to local, county, state and contract facilities where ICE detainees are housed, to provide orientation and coaching to the respective custody and medical staff members regarding the policies and procedures of the Managed Care Branch, DIHS.
• Provides coverage and support to other MCCs as needed (e.g., annual leave, TDY assignments, illness).
• Maintains accountability and monitoring of annual budgets/expenditures in conjunction with DIHS Financial Management Branch, and in accordance with all pertinent policies.
• Achieves and maintains status as certified Case Managers, Utilization Review / Utilization Management Professionals as directed by DIHS, through training and other means.

Knowledge Required

• Must have a professional background in health care with extensive direct patient care experience, preferably within a correctional setting.
• The MCC must be able to plan and organize her/his own workload and travel schedule utilizing the DIHS travel policies.
• Must remain flexible and be able to adapt to sudden changes in schedules and work requirements.
• Excellent verbal and written communication skills are essential.

Supervisory Controls