JOB SUMMARY
The Case Manager serves as a liasison between North Central Surgical Center, physicians, third party payors and auditors to ensure information and payment rules are met. Responsibilities include the review of medical records to determine the appropriateness and medical necessity of hospitalization. This position will also be responsible for coordinating and maintaining the appeals process for denied hospitalizations. These activities are to be performed in compliance with the philosophies, policies, procedures, goals, and budgets as established by the hospital''s governing board and corporate offices as well as all Federal, State, and local laws. Requires a high level of professional judgment and discretion in carrying out assignments, the ability to problem solve, a high degree of confidentiality, and the ability to work under pressure.
DUTIES INCLUDE:
Maintains systems for monitoring patient admissions and extended stays for appropriateness and medically necessity by:
- Reviews all preadmissions and admissions to observation and inpatient status within guidelines to assure criteria has been met for appropriate level of care.
- Reviews all inpatient admissions concurrently (according to guidelines) until dismissal to assure continued stay and discharge criteria have been met.
- Communicates effectively with the attending physician any questions concerning patient status.
- Communicates with the Medical Staff and Nursing Staff any utilization issues concerning patient care activities.
- Communicates with patients regarding their concerns, problems and/or understanding of their health insurance coverage.
- Contacts the Medical Director of Utilization Review Committee concurrently regarding any patient not meeting continued stay criteria and/or meeting discharge criteria but not being discharged.
- Identifies preliminary (working) admission diagnosis to enable a tentative DRG and corresponding average length of stay to be assigned to each inpatient stay.
- Acts as liaison between Hospital, physicians, patients and Medicare/Medicaid/Insurance review staff.
- Communicates, in a timely manner, with third-party payors to justify admission or continued stay.
- Performs preadmission and continued stay preauthorization for patients identified by Admissions as required this service.
- Adheres to Federal and State rules as outlined.
Anticipates and reviews denials and facilitates the appeal process by:
1.Anticipating and reviewing denials by payors for lack of medical necessity, inadequate medical information or delay in discharge; also intervening by written appeal to avoid loss of revenue.
2.Arranging physician-to-physician clinical reviews with insurance company, Medical Director and surgeon.
3.Writing denial appeal letters on behalf of the patient and/or the Hospital, when appropriate, to avoid loss of revenue.
4.Coordinating with the CNO and CFO (and other management as appropriate) to identify and correct weaknesses in the admission and patient care process that can mitigate future denials.
5.Issuing Notices of Non-coverage (insurance &/or Medicare) to patients as necessary.
Serves as a resource regarding reimbursement by:
- Maintaining knowledge regarding current regulations (PRO, JCAHO, AHA, etc.) which impact utilization review activities.
- Meeting with physicians, Hospital staff, review agencies, insurance companies and others (as relevant) in the assessment of utilization needs.
- Educating patients and patients'' families regarding Medicare regulations and issues, and notices of non-coverage when appropriate.
- Identifying risk issues concurrently with clinical reviews to provide the Hospital management with valid information on potentially compensable events; also communicating with the Director of Quality and Risk Management as needed.
Required Skills
KNOWLEDGE, SKILLS AND ABILITIES
- Requires fundamental knowledge of the revenue cycle process, which includes such things as patient access, utilization review, charge capture, HIM and patient accounting.
- Requires the advanced analytical and critical thinking skills necessary to audit patient care data, associated patient care documentation and identify variances in standards of care.
- Requires knowledge of rules and regulations pertaining to hospital reimbursement.
- Requires familiarity with managed care principles and an understanding of post-acute continuum of care.
- Requires the interpersonal skills necessary to maintain effective working relationships and interact effectively with staff, physicians, review agencies, insurance companies, patients and patients'' families.
- Requires the effective communication skills (both verbal and written) necessary to prepare documentation, write appeal letters and to provide education to staff and physicians regarding the revenue cycle process.
- Demonstrates the ability to be self-motivated, detail oriented and make independent decisions. Also demonstrates the ability to respond quickly and appropriately to customer requests.
- Demonstrates a working knowledge of the Hospital''s computer systems and proficiency in basic computer skills (i.e., data entry, word processing, spreadsheets, utilizing the internet, etc.). A basic understanding of database applications is desired.
- Demonstrates knowledge of and a commitment to North Central Surgical Center''s mission and values and the organization''s goal of providing world class service.
- Requires the physical ability and stamina to perform the essential functions of the position.
The above level of knowledge, skills and abilities are normally acquired through the successful completion of a Nursing program. A valid and current Registered Nurse license in the state of Texas is required. Two years of clinical experience is required. Two years of progressively responsible experience in a utilization review environment is preferred.
BENEFITS
Our competitive salary and benefits package includes medical and dental insurance, 401(k), paid time off and life insurance.
Required Experience