Responsible for the quality and resource management of all patients that are admitted to the facility from the point of their admission and across the continuum of the health care management. Works on behalf of the advocate, promoting cost containment and demonstrates leadership to integrate the health care providers to achieve a perceived seamless delivery of care. The methodology is designed to facilitate and insure the achievement of quality, clinical and cost effective outcomes and to perform a holistic and comprehensive admission and concurrent review of the medical record for the medical necessity, intensity of service and severity of illness.
Upholds and supports the philosophy, objectives, and policies of the Medical Center.
Performs admission and concurrent reviews in a timely manner utilizing criteria approved by the Utilization Review Committee. Determines priorities for the order in which patients need to be reviewed.
Applies appropriate clinical judgment in the concurrent review process to ensure that information in the medical records meet the criteria for intensity of care level of service for continued hospital stay and/or discharge.
Documents all deviations from criteria for continued length of stay and promptly discusses these with the attending physician and/or Medical Director.
Communicates daily, as needed, with the Medical Director, or his designee, regarding concurrent reviews and/or difficulties with resource utilization.
Participates actively in discharge planning; coordinating appropriate discharge plan based upon the identified needs of the patient and the availability of resources.
Functions as the liaison with the Medi-Cal/Medicaid field representative and other Medical/Medicaid providers within the hospital if applicable; completes TAR’s accurately and timely.
Communicates, as requested by insurance carrier, needed information regarding intensity of care and level of service. Abides with HIPAA regulations.
Attends regularly scheduled staff meetings including other department required meetings and educational programs.
Assists in the orientation process for new Case Managers and Discharge Planners.
Integrates with various departments in order to enhance patient outcomes.
Assists with general office duties, i.e., copying, faxing, mailing, filing, data entry, etc. when requested.
Interacts with insurance companies and 3rd party payers to obtain authorizations for continued hospital care.
Provides necessary documentation and communication to avoid Medicare, Medi-Cal/Medicaid, HMO and / or other insurance denials.
Performs retro reviews, when requested, on patients who have been discharged.
Assists in appeal process on any insurance denial when requested.
Regularly participates in scheduled case management LOS and hospitalist meetings and actively exchanges information pertaining to clinical documentation, plan of care affecting coding and reimbursement.
Participates proactively in the goals and objectives of the Case Management Department in reducing medically aberrant LOS, and establishes personal goals to achieve desirable outcomes organizationally.
Functions and collaborates with readmission reduction team goals.
Performs other duties as assigned or required.
EDUCATION, EXPERIENCE, TRAINING