AddressLocation - Remote
Hours are 8 hour shifts, with hours of operation from 7:30am until 6:30pm, No holidays and working Monday through Friday with a rotating weekend schedule of every 5th weekend.
Under minimal supervision, reviews and screens the appropriateness of services, the utilization of hospital resources and the quality of patient care rendered. Combines clinical, business, regulatory knowledge, and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. Through continuous assessments from admission through discharge, problem identification and education, facilitates the quality of health care delivery in the most cost effective and efficient manner. Utilizes best practice workflows, evidence-based screening criteria and critical thinking to maximize reimbursement.
PRINCIPLE DUTIES AND RESPONSIBILITIES:
Utilize the approved screening guidelines and strong understanding of disease processes to accurately determine severity of illness, intensity of service and medical necessity.
Evaluate the appropriateness of admission care and continuation of care.
Collaborates with providers and physician advisors regarding patient acuity and medical necessity for intensity of service.
Responds to pre-claim payor denials by facilitating peer-to-peer discussions to prevent post-bill denials.
Assesses readiness for discharge through continued stay review to evaluate medical necessity for continued hospital care.
Identify opportunities to improve progression in the transition of care through a safe discharge plan.
Serves as a liaison between Inpatient Case Management and payers, establishing relationships that positively impact financial outcomes.
Proactively identify issues throughout the hospitalization to improve the utilization of hospital resources.
Reviews and provides concise clinical information to Physician Advisor to ensure accurate information being provided to the corresponding governmental agencies and third-party payers.
Reviews and provides medical information for those patients whose financial reimbursement to the hospital is dependent upon information being provided to the appropriate government agencies and third-party payers.
Identifies inappropriate/inaccurate documentation that may potentially have legal and/or financial ramifications. Follows established guidelines for reporting issues.
Facilitate and coordinate involvement of medical staff, when appropriate, in responding to third party payers requests to ensure positive outcomes and maximal reimbursement of hospital services.
Educates healthcare providers regarding initial screening criteria, patient classification/status, utilization of resources and government regulations that impact the delivery of care.
Communicates electronically, written and verbally with third party payers to obtain necessary authorization for reimbursement of services.
Documents all communications in electronic record per departmental guidelines.
EDUCATION AND EXPERIENCE:
- Bachelor of Science in Nursing, required.
- Minimum 3-5 years of clinical experience preferred.
- Previous utilization management or case management experience preferred.
- Knowledge of outside regulatory agencies that interface with the institution.
