Registered Nurse, Senior Care Management - Remo...

Position Summary This job is Monday to Friday and is salaried. This is a remote role from the hours of 8am to 4:30pm with some flexibility. No direct patient contact, however, sites assigned can vary. ooking for a nurse that has experience in utilization review and past acute care experience. Responsibilities Position Summary Responsible for ensuring an efficient, cost-effective care management process by determining the patient’s medical necessity and financial liability through the coordination of insurance reviews and issuance of authorization numbers through submission of required clinical information. Essential Functions Guides the care managers in the performance of medical record reviews for medical necessity of admission and the placement of the patient in appropriate bed status. Works directly with the Care Management department, the Business Office, Patient Access, and along with the Hospital’s Revenue Cycle to ensure quality and efficiency of certain elements of claims processing, denial prevention, and denial management. Retrieves designated reports from Allscripts Care Management and other systems in an effort to identify, organize, prioritize, and validate the requests for pre-authorizations and/or authorizations have been obtained or that appropriate, timely follow-up has been completed. Responds to internal and external inquires in person, through telephone calls, or electronically, routing calls to appropriate individuals. Retrieves and disseminates face sheets, consultation requests, clinical, and other information, as deemed necessary, to appropriate individual(s) in a timely manner. Submits/faxes required/ requested clinical information to insurance company for authorization of patient hospitalization. Coordinates insurance company requests and authorization numbers with the care managers and Patient Access Department. Enters authorization numbers and appropriate payer documentation/correspondence into the Allscripts system. Completes retrospective reviews utilizing the daily discharge list to validate that all patients had an initial medical necessity review completed and the outcome is favorable for reimbursement of the designated bed status. If an initial admission medical necessity was not completed, the Care Manager, Senior will assign the review to be completed by a unit Care Manager or will complete the review. Note: These retrospective reviews are time sensitive, due to the coding and billing guidelines and need to be completed within 3 days of the patient’s discharge. Any discrepancy needs to reconcile immediately and/or notification of the appropriate HIM or Business Office Staff to “pend” the account. Completes retrospective medical necessity review for all readmitted patients within 30 days to identify if there is any quality of care and/or premature discharge. If a quality-of-care issue is identified and the patient’s readmission may be directly related to a failure of the treatment or discharge, discuss findings with the Physician Advisor and coordinate the processing and billing of these two admissions as one DRG. If no quality of care or failure of treatment or discharge plan is identified, coordinate with the business to prepare each account for a separate DRG payment. Assist in appealing existing denials by communicating necessary information to the payers. Assists in denial prevention by proactively communicating with care management staff, the bedside nurses, physicians, and the Physician Advisor in obtaining pertinent information. Also actively assists with the request by the payer(s) for Peer-to Peer reviews. Demonstrates the knowledge and skills necessary to provide appropriate care in consideration of the growth development, and social needs of pediatric, adolescent, adult, and geriatric patients. Enhances professional growth and development through participation in educational programs, current literature, in-services, meetings, and workshops. Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state, and local standards. Maintains compliance with all Orlando Health policies and procedures. Qualifications Education/Training  Graduate of an approved school of nursing. Licensure/Certification Maintains current license as a Registered Nurse (RN) in Florida. Certification as an InterQual trainer within six (6) months from date of hire. Experience Five (5) years of acute clinical experience to include at least two (2) years in utilization management, chronic disease management, care management, care coordination,