Job Description

Location: Morton Hospital
Posted Date: 9/9/2021

POSITION SUMMARY:
Coordinates case management activities to include utilization management and discharge planning. Responsible for hospital compliance with third party payor to maximize hospital reimbursement and minimize insurance denials for hospital services rendered. Advocates for the patient while protecting the resources of the hospital and health care system.

HOURS: 40 hour days 7a-3:30p

KEY RESPONSIBILITIES:
Responsibilities:
• Reviews and establishes appropriateness of admission according to DSM IV & ASAM criteria within 24 hours of admission.
• Determines accurate status of patient as either inpatient or outpatient.
• Provides patient’s insurance with necessary notification of services and concurrent review of the plan of care according to the insurance’s process.
• Determines accurate level of care throughout the hospitalization according to DSM IV & ASAM criteria.
• Ensures that all standard forms associate with insurance are signed by the patient at the required intervals (i.e. Medicare Notification of Coverage.)
• Documents pertinent information including, but not limited to, insurance authorization number, insurance requests for contact with member in the electronic medical record.
• Facilitates daily treatment rounds as a member of the treatment team to ensure progression of patient’s plan of care.
• Notifies patient and/or appropriate person of notice of non-coverage and appeal process according to procedure.
• Identifies and pro-actively avoid delays in service or treatment.
• Identifies actual delays in service or treatment. Enter occurrence and action into the electronic medical record.
• Identifies patients whose care can be safely provided in an alternative setting and discuss transfer with physician.
• Acts as liaison with the business office to coordinate patient insurance coverage and advises patient coverage.
• Counsels patients and families about realistic discharge plans.
• Responds to discharge needs by exploring and using outside resources creatively.
• Manages insurance denials of coverage.
• Resolves Revenue Recovery issues.
• Participates in external agency reviews regarding utilization management and discharge planning.
• Refer all cases not meeting criteria for admission and continued stays to the Administrative Director.
• Maintains professional boundaries with patients.
• Performs other duties as assigned.

UM Reviews and Denial Support
• Perform InterQual Admission Assessments on all new admissions and forward the reviews to insurers as needed. Answer questions from the insurers and continue to provide any additional clinical information they request. Timely reviews to be provide so payers have sufficient time to review case and respond quickly.
• Communicate in real time with physicians on any patients not meeting criteria and establish a course of action.
• Work collaboratively with the MDs to help them understand documentation issues or any leveling issues or any leveling issues. Inform physician partners on Inpatient vs. Observation criteria or acute care criteria.
• Provide education to them regarding Inpatient vs. Observation criteria or daily care criteria.
• Act as liaison to managed care case managers for evaluating medical management of patients, referring questions to Medical Directors and/or payers when appropriate.
• Perform concurrent/daily InterQual reviews on assigned patients and document when InterQual criteria is not met.
• Forward all reviews to insurers on a timely basis.
• Answer any questions from insurers.
• Perform concurrent denial management to resolve issues prior to discharge of patient. Inform Directors/designee regarding outcome.
• Upon receipt of admitting or daily denials from insurers, review the case and provide the insurer with additional clinical information for the insurers' reconsideration.
• Complete the clinical record and profile on a patient profile in Allscripts or a Steward designated software tool. Utilize the Allscripts tool appropriately so all fields are complete, all clinical information is fully recorded, all changes to a patient's clinical condition is recorded, all interaction with insurers, RNs, MDs is documented, as appropriate.
• Copy the Allscripts clinical information and place in medial record, as appropriate.
• Finalize authorization for stay for all covered days prior to case closure The RN Care Coordinator provides resource 365 days per year.
• Rotate to other units of the Hospital including the ED as necessary and as directed by Hospital management.
• Holidays will be scheduled as necessary based on operational needs.
• Weekends will be scheduled as necessary and in accordance with the collective bargaining agreement.
• Collaborate with the Interdisciplinary team to create an individualized discharge plan for high-risk patients, as needed ensuring appropriate level of services are scheduled for the patient.
• Communicate pertinent patient information, on an as needed basis, with skilled nursing facilities, community health Agencies, physicians and other staff to insure all post-acute clinical information is provided.
• Be aware of disease management programs and services in existence within the Steward network to use network resources, as appropriate. Provide patient education and family teaching, on an as needed basis.
• Act as an advocate for the patient.
• Maintain daily tracking tools, to support data reporting, including but not limited to the following list
• Supports MorCap in maintaining the financial and clinical outcomes for the service.
• Support the Steward physician network by coordinating with the Steward ambulatory/community care coordinators to ensure patient information is communicated and the transitions of care from inpatient to outpatient is planned and in place. This function will evolve over time as the community / ambulatory care coordinators are put in place.
• Identify opportunities to educate physicians on areas requiring documentation improvement and/or other improvements.
• Ensure that resources are managed in a cost-effective manner while achieving positive clinical outcome
• Identify service needs, systems issues and opportunities for improvement for the Department Review out-of-network referrals and scheduled procedures in order to manage the financial and utilization management of managed care contracts. Collaborate with the PCP and/or specialist to determine the possibility of redirecting care to/within the Steward network.
• Assist with the development of clinical guidelines, as needed.
• Maintain current knowledge of regulatory requirements including changes to payer requirements, reporting and regulatory requirements.

Management of Time and Resources:
• Completes work assignments within an acceptable time frame.
• Uses time and resources to the best possible advantage for successful completion of job responsibilities.
• Develops and maintains efficient working relationships.
• Is reliable in respect to attendance and punctuality.
• Recognizes the importance of team efforts and partners with others to achieve positive outcomes.

Quality:
• Participated as a member of the healthcare team to ensure quality services.
• Accepts responsibility for all work performed and takes appropriate corrective action as needed.
• Attends Staff Meetings
• Offers creative solutions or alternatives to issues or concerns.
• Continually strives to improve the quality of work by participating in the Quality Improvement activities for the department.
• Responsible for ongoing development of his/her work skills using available resources (i.e.: Steward University, inservices, formal educational programs, other work groups and on-the-job training).
• Assists in the orientation of others and actively participates in mentoring.
• Recognizes and seeks assistance/consultation when appropriate.

CUSTOMER SERVICE SKILLS:
• Is cooperative in interactions, treating customers with courtesy, respect and compassion.
• Is patient when responding to questions and answers questions appropriately.
• Responds to requests in a timely manner.
• Handles interruptions in a skillful way.
• Maintains a professional appearance and demeanor.
• Strives to prevent/resolve customer concerns to the customer’s satisfaction.

REQUIRED KNOWLEDGE & SKILLS:
• Good communication and interpersonal skills
• Ability to create a friendly, caring environment for patients, families, visitors, and staff.
• Displays willingness and flexibility in learning new functions.
• Strong data analysis skills.
• Ability to work in an interdisciplinary team of professionals (medical, nursing, counseling).
• 42 CFR – Part 2 law governing patient confidentiality in Substance Use Disorder Treatment Programs.


EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:
Education:

• BSN preferred
• Evidence of continuing professional development

Experience:

• Recent experience in Level 4.0 or 3.7 Inpatient Detoxification required.
• Recent experience in Level 4.0 or 3.7 case management preferred.
• InterQual experience preferred
Certification/Licensure:

• MA RN License
• ANCC preferred
Software/Hardware:

• Basic computer skills required.
• Experience with EMR, particularly Meditech, preferred.

Application Instructions

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