Job Description

 

Summary

The Case Manager Admission & Denial Coordinator assures appropriate patient access to necessary services and provides guidance in the determination of a patient's admission status; works cooperatively with Physicians, physician offices, PACU, Cardiac Cath Lab, patient access, case management department and payers; combines clinical, business, and regulatory knowledge and skills to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided; collaborates with physicians, case managers, revenue cycle personnel, payers, and others to appeal individual denials and trend issues related to contract performance.

Responsibilities

Provides guidance per payer guidelines in the determination of patient's admission status; intervenes in opportunities to manage patient's needs without an admission; identifies patients at risk for prolonged hospitalization such as frail elderly, uninsured, medically complex and socially dysfunctional; identifies patient readmissions within 30 days and communicates with unit case manager. Serves as Case Management liaison; verifies appropriate status and authorization for scheduled surgery; educates Physicians and nurses about admission and observation criteria; provides guidance per payer guidelines in the determination of patient's admission status; evaluates pre-op and post-op for extended care or change in level of care; participates as a key team member of PACU and Cardiac Cath Lab. Establishes effective partnership between physician and case manager; creates cooperative working relationship with physician office staff; ensures real time communication with unit case manager; works closely with house supervisor to ensure smooth access to services; aligns work process to enhance the services of Patient Access; develops rapport with outside providers to ensure timely provision of services. Serves as Case Management liaison for physician and physician office; educates Physicians and physician office staff about admission criteria; provides guidance per payer guidelines in the determination of patient's admission status; educates and guides physicians in appropriate documentation to clarify needed level of care. Determines the appropriateness of medical services to be appealed; obtains necessary clinical information from the following as needed: Physician, Clinical Staff, Case Management Staff, Patient Accounts and other sources as needed; evaluates information to determine one whether to challenge the denial; prepares timely clinical justification of services and submits to payer; submits payer denial notification, appeal letter and supporting documentation to physician's office or payer denial notification stating appropriateness for denial to patient accounts; submits payer denial notification and appeal letter to patient accounts; retains physician collaboration and medical necessity appeal; provides feedback and education to prevent possible future denials. Inputs denied/appeal information; monitors status of pending appeals; measures and trends appeal success rates; tracks and identifies payer trends including reports to appropriate internal customers; reports results specific to payers up through Revenue Cycle; presents denial management information including challenged denials, accepted denials and recovery to Utilization Management Committee. Follows organizational and departmental guidelines for documentation of services provided; documents identified high risk and readmitted patients; facilitates accurate medical record documentation by guiding physician, physician office staff, PACU staff and Cardiac Cath Lab staff. Provides information regarding appropriate patient status, level of care, required documentation and differing payer regulatory guidelines; educates, informs, and guides patients in the appeals process; refers patient to health records, patient accounts and other departments as necessary to complete appeal process; orients, supports, and mentors employees new to the department. Other duties as assigned.


Other Information

REQUIRED: 2+ years related experience

Education

Essential:
* ASSOCIATE'S DEGREE


Credentials

Essential:
* CERTIFIED CASE MANAGER (CCMC)
* REGISTERED NURSE (RN)


Work Schedule: 8-hours, Days, Varied

Physical Requirements and working conditions for this position will be provided to you upon interview.

 


Application Instructions

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