Full Job Description
The individual in this position is responsible to facilitate and support an effective Utilization Review program within the Case Management department, which may be centralized within a specific market or group. The individual in this position has overall responsibility to ensure that care is provided at the appropriate level of care based on medical necessity and assess the patient for transition needs to promote timely throughput, safe discharge and prevent avoidable readmissions. This position manages medical necessity process for accurate and timely payment for services which may require negotiation with a payer on a case by case basis. This position integrates national standards for case management scope of services to include:
• Provides assistance to the Director of Case Management in the management of the Utilization Review/ Central Utilization Review department, but not limited to, hiring/training/managing staff, schedule coordination, analysis and reporting, interfacing, collaborating and working closely with the other departments.
• Accountable for compliance with state and federal regulatory requirements, TIC accreditation standards and Tenet policy.
• Provides education to physicians, physician advisors, Case Management staff, and other hospital leaders as needed. Identify and provide physician education and feedback on hospital utilization and disputes/denials data.
• Review weekly Case Management Utilization Review (UR) and Continuing Care (CC) scorecards/metrics, Observed/Expected Length of Stay, Authorizations and Downgrades. Provides reports to DCM and hospital leadership as requested.
• Maintains knowledge of current contractual arrangements with Health Plans and Vendors. Partners with Managed Care representatives in JOC and other payer meetings to collaborate and communicate better outcomes.
• Organize the concurrent authorization process to meet utilization management needs and monitor turn-around times to meet health plan requirements. Implement and monitor processes to prevent payer disputes.
• Ensure medical necessity and revenue cycle processes are completed accurately and in compliance with Tenet policy as well as any state or federal program requirements.
The individual's responsibilities include the following activities: a) accurate medical necessity screening and submission for Physician Advisor review, b) securing and documenting authorization for services from payers, c) managing concurrent disputes, d) collaborating with payers, physicians, office staff and ancillary departments, e) timely, complete and concise documentation in the Tenet Case Management documentation system, f) maintenance of accurate patient demographic and insurance information, g) identification and documentation of potentially avoidable days, h) identification and reporting over and underutilization, i) and other duties as assigned.
Qualifications:
QUALIFICATIONS:
Required qualifications include an active Registered Nurse license with at least two years acute hospital patient care, hospital case management, utilization review, healthcare, or leadership experience. B.S.N. preferred, ***unless higher degree required for Magnet Hospital Status. Accredited Case Manager (ACM) preferred. Acute hospital case management or supervisory experience preferred. Required skills include demonstrated organizational skills, excellent verbal and written communication skills, ability to lead and
coordinate activities of a diverse group of people in a fast-paced environment, critical thinking and problem solving skills and computer literacy.
