Job description:

Job Summary

Provides overall coordination in the delivery of medical services and discharge planning for a specified patient population. Performs concurrent and retrospective review of patient medical records for purposes of utilization review, compliance with requirements of external review agencies including governmental and non-governmental payers and quality assurance agencies. Promotes a cooperative and supportive relationship as liaison with patient, family, facility staff, physicians, funding representatives and community agencies. Ensures continuity in the handoff of patient clinical information from the hospital to other involved healthcare entities. The duties of the acute care Case Manager may be performed as in the integrated or triad model.

Job Responsibilities

• You will communicate proactively and cooperatively with Patient Access, Patient Account Services (PAS) and Central Verification Office (CVO) personnel to ensure proper pre-certification and consistency of admissions status designation between physician order and EMR.
• You will communicate known changes to patient payer information and other relevant financial characteristics of coverage to appropriate admissions and billing personnel.
• You will proactively ensure that required clinical justification is provided to third-party payers to obtain recertification for continued hospitalization and treatment and that transfer of this information, together with days approved and contact information is provided timely to the PAS and CVO via computerized insurance review documentation.
• You will serve as a liaison between third-party payers, patient access PAS, and CVO to ensure communication of all pertinent information regarding level of care, billing and reimbursement.
• You will work with the patient and family to identify alternate financial resources available to meet the cost of necessary post-discharge needs or to recommend alternate care options when necessary funding is unavailable.
• You will proactively initiate an expedited appeals process with payers and communicates with denials management regarding anticipated or verified denials and cooperates with denials management to provide additional clinical information for appeals.
• You will educate patient and family on case manager role and process for contacting the case manager for questions.

Qualifications:

• RN licensure in the state of TX or Compact State.
• Associates Degree or BSN completion within 3 years of hire date
• Must have Case Management experience within the acute care setting min 2 years

Why is This a Great Opportunity:

Great benefits. Relo offered!