Job Summary:

This role is responsible for the review of medical records for appropriate admission status and continued hospitalization. Works in collaboration with the attending physician, consultants, second level physician reviewer and the Care Coordination staff utilizing evidence-based guidelines and critical thinking. Collaborates with the Concurrent Denial RNs to determine the root cause of denials and implement denial prevention strategies. Collaborates with Patient Access to establish and verify the correct payer source for patient stays and documents the interactions. Obtains inpatient authorization or provides clinical guidance to Payer Communications staff to support communication with the insurance providers to obtain admission and continued stay authorizations as required within the market.

Essential Job Duties:

• Conducts admission and continued stay reviews per the Care Coordination Utilization Review guidelines to ensure that the hospitalization is warranted based on established criteria and critical thinking. Reviews include admission, concurrent and post discharge for appropriate status determination.
• Ensures compliance with principles of utilization review, hospital policies and external regulatory agencies, Peer Review Organization (PRO), Joint Commission, and payer defined criteria for eligibility.
• Reviews the records for the presence of accurate patient placement orders and addresses deficiencies with providers.
• Ensures timely communication and follow up with physicians, payers, Care Coordinators and other stakeholders regarding review outcomes.
• Collaborates with facility RN Care Coordinators to ensure progression of care.
• Engages the second level physician reviewer, internal or external, as indicated to support the appropriate status.
• Communicates the need for proper notifications and education in alignment with status changes.
• Engages with Denials RN/Revenue cycle vendor to discuss opportunities for denials prevention.
• Coordinates Peer to Peer between hospital provider and insurance provider, when appropriate.
• Identifies opportunities for process improvement.
• Performs other duties as assigned.

#CareCoordinationCSH 

Required Education and Experience:

Minimum two (2) years of acute hospital nursing experience or a Masters degree in Case Management or Nursing field in lieu of 1 year experience.

Preferred:

• Graduate of an accredited school of nursing (Bachelor's Degree in Nursing (BSN)) or related healthcare field.
• At least five (5) years of nursing experience.

Required Licensure and Certifications:

RN license in the state(s) covered is required.

Preferred:

Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification preferred.