Director Denials Management Jobs in Riverside, RI

Position: RN Case Manager

Department: Care Management

Schedule: Part Time, Per Diem

POSITION SUMMARY:

The RN Case Manager (CM) is responsible for overseeing the appropriate level of care and collaborates with the Social Work partner regarding discharge planning with a particular focus on medically complex discharge planning. The RN CM will be assigned to selected areas of the Hospital based upon department staffing and coverage. The RN CM will collaborate with SW Care Coordinator as a team to meet the needs of the patients within unit assigned. As this is an evolving position, duties and responsibilities may vary based on specific assignments and additional tasks may be added as the position is further developed.
Each staff member will participate in a departmental orientation focused on Case Management Standards of Practice. All staff will be cross-trained and oriented to the ED Case Management Practice.

ESSENTIAL RESPONSIBILITIES / DUTIES:

UM Reviews and Denial Support

• Perform Interqual Admission Assessments on all new admissions and forward the reviews to insurers as needed. Answer questions from the insurers and continue to provide any additional clinical information they request. Timely reviews to be provided so payers have sufficient time to review case and respond quickly.
• Communicate in real time with physicians on any patients not meeting criteria and establish a course of action. Work collaboratively with the MDs to help them understand documentation issues or any leveling issues. Inform physician partners on Inpatient vs. Observation criteria or acute care criteria.
• Act as liaison to managed care case managers for evaluating medical management of patients, referring questions to Medical Directors and/or payers when appropriate.
• Perform daily InterQual reviews on assigned patients and document when InterQual criteria is not met. Forward all reviews to insurers on a timely basis. Answer any questions from insurers. Perform concurrent denial management to resolve issues and ensure authorizations prior to discharge of patient. Inform Directors /designee regarding outcome.
• Upon receipt of admitting or daily denials from insurers, review the case and provide the insurer with additional clinical information for the insurers' reconsideration.
• Complete the clinical record and patient profile in Allscripts or a BMCHS-designated software tool. Utilize the Allscripts tool appropriately so all fields are complete, all clinical information is fully recorded , all changes to a patient's clinical condition are recorded, all interaction with insurers, RNs, MDs is documented, as appropriate.
• Copy the Allscripts clinical information and place in medical record, as appropriate.
• Finalize authorization for stay for all covered days prior to case closure.*

Discharge Planning and Execution:

• Review initial Admission Assessments and proposed discharge plans outlined by the SW Care Coordinator. Collaborate with SW Care Coordinator on discharge plan. Identify the patients/discharges that may be complicated and review these discharges with the Social Worker.
• Coordinate and monitor discharge planning activities for an assigned patient population and provide support as needed to the SW Care Coordinator and administrative staff managing the discharge process.
• Collaborate with the Interdisciplinary team to create an individualized discharge plan for high-risk patients, as needed, ensuring appropriate level of services are scheduled for the patient.
• Inform PCPs, attending physicians and clinical staff on alternative discharge options including high-tech home care, skilled nursing facility capabilities, and disease management initiatives in collaboration with SW Care Coordinators.
• Communicate pertinent patient information, on an as needed basis, with skilled nursing facilities, community health agencies, physicians and other staff to insure all post-acute clinical information is provided. Information to be provided on a timely basis to not delay discharge.
• Be aware of disease management programs and services in existence within BMCHS to use network resources, as appropriate.

Boston Medical Center South:

• Provide patient education and family teaching, on an as needed basis.
• Act as an advocate for the patient.
• Facilitate/coordinate multidisciplinary rounds on assigned patient care units, at a minimum of Monday - Friday.
• Attend UMCM meetings as appropriate

Other Responsibilities:

• Maintain daily tracking tools to support data reporting, including but not limited to the following list:
• Avoidable Days
• Saved Days
• Interventions
• Readmissions
• Interqual criteria
• Projected Discharge Date
• Payer issues
• Support the Care Coordination Manager/Director in maintaining the financial and clinical outcomes of the Care Coordination Department.
• Support the BMC South physician network by coordinating with the BMC South ambulatory/community care coordinators to ensure patient information is communicated and the transitions of care from inpatient to outpatient is planned and in place. This function will evolve over time as the community/ambulatory care coordinators are put in place.
• Identify opportunities to educate physicians on areas requiring documentation improvement and/or other improvements.
• Ensure that resources are managed in a cost-effective manner while achieving positive clinical outcome
• Identify service needs, systems issues and opportunities for improvement for the Department
• Participate in the Hospital Quality Improvement Plan through unit and/or divisional quality control/quality improvement activities.
• Report deviations in quality care to the Manager/Director of Care Coordination.
• Assist with the development of clinical guidelines, as needed.
• Maintain current knowledge of regulatory requirements including changes to payer requirements, reporting and regulatory requirements.
• Demonstrate effective leadership skill
• Attend weekly Care Coordination meetings, when scheduled to work.
• Complete all paperwork required for regulations e.g., LTCF, OBRA screening, Condition/Code 44 paperwork.
• Perform InterQual reviews on assigned patients and working with insurers to provide clinical information, answer questions, obtain insurance authorization for patients.
• Collaborate with Social Worker (SW) Care Coordinators on the units who will be responsible for the development and execution of patient discharge plans.
• Coordinate with the SW Care Coordinators for clinically difficult discharge plans.
• Review reports on the Department's performance including but not limited to: LOS, clinical denials and appeal status, avoidable days, time of discharge, proper level of documentation.
• Work with Care Coordination Manager/Director to develop educational needs and identify strategies to accomplish objectives of the Department

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

JOB REQUIREMENTS

REQUIRED EDUCATION AND EXPERIENCE:

• Graduate of an approved school of nursing.

• Recent experience in acute care setting involved with clinical activities and/or a managed care environment working in case management, recent experience in a case management role or related role

PREFERRED EDUCATION AND EXPERIENCE:

• BSN

• InterQual experience

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

• Active MA RN license

CERTIFICATES, LICENSES, REGISTRATIONS PREFERRED:

• Case Management certification preferred

KNOWLEDGE, SKILLS & ABILITIES (KSAs):

• Excellent computer skills including managing work against performance metrics and reporting on key indicators important to the department

• Strong computer skills with knowledge and proficiency with Microsoft Word, Excel and PowerPoint

• Demonstrated data analytic skills.

• Demonstrated skills in working collaboratively with physicians, managers and other team members

• Demonstrated skills in organizing and facilitating interdisciplinary teams to ensure timely discharge

• Evidence of continued professional development

Compensation Range:

This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensures as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, BMCHS offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), discretionary annual bonuses and merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family well-being.

NOTE: This range is based on Boston-area data, and is subject to modification based on geographic location.

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