Description

POSITION SUMMARY:

Coordinates all admissions including interfacility transfers, and screens for appropriateness of admissions – targeting specific admission criteria requirements and medical necessity for admission. Utilizes Interqual-screening criteria for all admissions and observation status patients. Obtains physicians orders prior to admission. Must possess a thorough knowledge of hospital 3^rd party reimbursement rules and regulations. Works collaboratively with interdisciplinary staff internal and external to the organization, and participates in quality improvement and evaluation processes related to the management of patient care. Responsible for working closely with Physician office in obtaining authorization on surgical cases.

­POSITION EDUCATION/QUALIFICATIONS:

• Graduate from an accredited school of Vocational nursing required
• Licensed Vocational Nurse with the State of Texas is required.
• Current license/valid permit to practice in the State of Texas will be required of all certified individuals.
• Candidate must demonstrate proficiency in both the English and Spanish language.

JOB KNOWLEDGE/EXPERIENCE­:

• Knowledge in the areas of case management and utilization management, experience with Managed Care and utilization management as it relates to third-party payers preferred.
• Knowledge and understanding of Medicare and Medicaid guidelines and regulations pertaining to utilization review and discharge planning.
• Understand insurance benefits and medical terminology
• Good Written and verbal communication skills required
• Previous healthcare experience (2-3 yrs) is required, hospital experience preferred
• Communicates clearly and concisely and is able to work effectively with other employees, patients and external parties
• Medical Terminology, ICD-10 Codes, CPT Codes, HCPCS Codes, Modifier knowledge preferred

POSITION RESPONSIBILITIES:

• Collaborates with already existing programs and departments to ensure appropriate resource utilization by all patients being followed in a caseload
• Works with nurse managers, other clinical departments, and division directors in program development.
• Works closely as a Liaison with Physician office in obtaining authorization by calling insurance company and submitting all clinical notes to support surgical procedure.
• Verifies all CPT Codes for Inpatient and Outpatient status
• Appropriately monitor and verify benefits all accounts on the daily schedule and pre-admission roster for the next day’s services
• Obtain policy exclusion, payable, billable, authorization number on all implants
• Asking insurance if procedure is considered cosmetic, does Implant require authorization?
• Obtained approval dates, CPT Codes, validate approval is for DHR.
• Obtains date of injury, compensable bodily injury, adjuster’s name, onset of illness and claim number, for worker’s compensation claims.
• Document clearly and concisely all patient benefit information on accounts through the patient accounting system (Pre-cert screen, account notes section of Paragon and ORM schedule).
• Provides orientation and ongoing education specific to case management.
• Acts as a consultant for both facility and physician’s office personnel
• Performs ongoing evaluation of case management program.
• Participates in daily rounds, providing education to other team members
• Participates in revenue cycle meetings.
• Assesses the patients within the caseload to identify needs, issues, resources, and care goals.
• Through proper reporting mechanisms, completes case management assessment, reviews admitting diagnoses/problem(s), determines plan to address client’s needs, and optional/preferred level of care. Develops a discharge plan early on in admission.
• Implements and coordinates interventions that will lead to goals in plan.
• Monitors the effectiveness of the plan.
• Participates in case finding and preadmission evaluation screening to ensure reimbursement.
• Identifies potential transition planning problems in a timely manner to set up services required.
• Works with attending physician and care team members to move patient through the hospital system and set up appropriate services or referrals.
• Identifies need for new resources if gaps exist in service continuum and initiates creative care delivery options.
• Daily responsibilities:
• Reviews the medical records of all observation and inpatient admissions to determine the medical necessity for admission and continued stay, using pre-established criteria (InterQual or Milliman) with appropriate frequency and Obtain physician’s orders if necessary.
• Establishes planning to determine goals and objectives and care setting to optimally meet patient needs
• Conducts necessary conferences and team meetings regarding specific patient needs.
• Proactively affects system to facilitate efficient flow of care.
• Coordinate interfacility upgrades request as per policy.
• Recognizes National Patient Safety Goals and Core Measures as applicable to the patient populations served.
• Plays an essential role in assisting physicians, nurses, and staff with an accurate determination of a patient’s observation status. The case manager is an important resource in preventing denials.
• Consults with physicians, nursing, admitting, and outside insurance case managers to determine the appropriate status of patient.
• Must take telephone orders from physicians changing patient status from observation to inpatient admission
• Accurately applies InterQual or Milliman criteria 95% of the time in determining status. Refers appropriately to the PA when medical decision making determination is necessary.
• Consistently follows Condition Code 44 policy when IP status requires changing to Observation for Medicare patients 95% of the time.
• Consistently follows the Observation policy for all other payers. (correct determination of start time)
• Reviews the medical records of all inpatient admissions to determine the medical necessity for admission and continued stay, using pre-established criteria.
• Assists and educates attending physicians on an on-going basis.
• Refers cases not meeting criteria appropriately, following contract requirements for all other payers.
• Interacts, communicates, and intervenes with multidisciplinary healthcare team in a purposeful, goal-directed fashion. Works proactively to maximize the effectiveness of resource utilization.
• Establishes a means of communicating and collaborating with physicians, other team members, the patient’s payers, and administrators.
• Utilizes appropriate resources in cases that present ethical dilemmas.
• Maintains a proactive role to ensure appropriate documentation concurrently to minimize inefficient resource utilization and prevent loss of reimbursement.
• Reviews physician documentation and, when needed, follows procedures to seek clarification of documentation relative to diagnosis and comment, on the patient’s clinical state
• Other duties as assigned