RN Clinical Coordinator, Case Management, 32-Hours, Days, Monday through Friday, Varied day off during the week

Overview

You Matter Here!

Heywood Healthcare values our employees! We offer competitive wages, great benefits and generous earned time off. Come work where you will matter!

 

Hours: 32-Hours, Days, Monday through Friday, Varied day off during the week

Responsibilities

ESSENTIAL FUNCTIONS

 

Utilization Management

Utilization Review and Care Transitions & Coordination

• Providing clinical information to payers, monitoring length of stay, seeking necessary care authorizations and utilizing the InterQual Program; appealing denials as indicated within a timely fashion.
• Review all new admissions and Observation patients within 24 hours of admission against High Risk Screening Criteria and documents outcome within the UM EMR.

• Follow-up on lack of documentation for medical necessity, supporting documentation with discipline identified. Track and trend opportunities for improvement resulting in late Insurance Reviews, longer lengths of stay;  including educating  providers  to Interqual Criteria used for determining Admission or Observation status.

• Completes utilization reviews daily and/or as required by insurer, (concurrent and retro) for medical and/or psychiatric appropriateness according to Hospital's approved criteria timely and efficiently.
• Assesses, intervenes, evaluates and determines level of care to establish accurate admission and/or observation status; demonstrates basic knowledge of DRG reimbursement, evidenced by standardized measures for length of stay and                  acuity level status designation.
• Demonstrates clinical expertise specific to the issuance of ABN/HINN notice to patients and/or legal significant other and care progression. Keeping physician and team informed of status change and documenting status.
• Provides education and information to patient, family and care providers as it pertains to continuing care, care management, LOS, re-hospitalization and assure understanding of disease management.

Multidisciplinary Team Rounds & IDT Meetings

• Participates in discharge planning rounds daily. 
• Works collaboratively with a multidisciplinary team to determine each patient's needs concurrently including post-acute care when needed; addresses LOS issues, appropriate leveling of patient status; addresses potential needs, resources, referrals for other disciplines etc.

Quality & Statistical Data

• Reviews medical records for abnormal findings, complications, delays, and deviations from expected clinical outcomes reports such to Provider and/or Director to maintain an efficient, cost-effective episode of care for each patient and documents intervention provided.
• Acquires knowledge to keep up with changes in technology and regulations.
• Utilizes knowledge to redesign systems for improving performance.
• Continuously prioritizes projects, activities, and tasks to ensure deadlines and customer needs are met..
• Assists with the preparation of reports/statistics as it pertains to staff-specific workflow.

Denials/Appeal Process

• Completes assessment of denial within 1 week providing supporting documentation with outcome of review; documents intervention in the UR EMR section.
• Prepare written appeal letters, termination letters, discharge notices, MOON and IMs when appropriate as per regulatory standards and department policies.
• Report any variances, trends to director.
• Submits denials/appeals when completed to the department secretary for processing.

Discharge Planning

• Communication: builds rapport and responds to needs of physician, reviewers for managed care plans, healthcare team members, 3rd party payers, outside reviewers and vendors to enhance internal and external customer service satisfaction.
• Responsible for completing nursing sections of the SNF Level of Care forms for Mass Health patients in need of care, SNF placement, timely and efficiently and other forms assisting in transition of care as identified and collaborates with the social worker. In the event of an emergency, Care Coordinator may complete the form in full and process it to help expedite discharge planning process and length of stay.

The Discharge Planning Process

• Completes discharge planning assessments timely, efficiently and completely following regulatory standards and departmental policies assuring appropriate patient flow.
• Appropriately levels patient for home discharge with or without services or to another type of facility such as a SNF,