[Hiring] RN Care Manager, Acute Sr. @Orlando Health

Role Description

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.

Responsibilities

• 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 to identify, organize, prioritize, and validate requests for pre-authorizations and/or authorizations.
• Responds to internal and external inquiries in person, through telephone calls, or electronically, routing calls to appropriate individuals.
• Retrieves and disseminates face sheets, consultation requests, clinical, and other information to appropriate individuals in a timely manner.
• Submits/faxes required/requested clinical information to insurance companies 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.
• Completes retrospective medical necessity review for all readmitted patients within 30 days to identify any quality of care and/or premature discharge issues.
• Assists in appealing existing denials by communicating necessary information to the payers.
• Assists in denial prevention by proactively communicating with care management staff, bedside nurses, physicians, and the Physician Advisor.
• 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.
• Assists Business Office personnel in preparing appropriate documentation relating to the admission, denials, and appeals process.
• Communicates with the payer(s) to facilitate covered-day reimbursement authorization for assigned patients.
• Escalates cases to the Physician Advisor when the patient is not satisfying criteria and/or a quality-of-care concern is identified.
• Assists Care Manager to identify patients with barriers to discharge and those at high risk of readmission.
• Discusses High Risk Length of Stay patients or complex situations to assist in expediting discharge/transfer to a lower level of care.
• Reviews payer requirements and government regulations to ensure compliant, safe healthcare.
• Assigns tasks to care management assistants and appropriate referrals to SW Care Coordinator.
• Interprets problems and selects appropriate solutions based on past situations.
• Plans events expected to occur from one to four weeks, or monthly.
• Regularly contacts employees to discuss issues of moderate importance and to respond to inquiries.
• Requires regular external contacts to discuss issues of moderate importance and to respond to inquiries.
• Requires extensive knowledge of their professional discipline and a working knowledge of related fields.
• Performs other duties as assigned or required.

Qualifications

• Graduate of an approved school of nursing.
• Maintains current license as a Registered Nurse (RN) in Florida.
• Certification as an InterQual trainer within six (6) months from date of hire.
• Five (5) years of acute clinical experience to include at least two (2) years in utilization management, chronic disease management, care management, care coordination.

Benefits

• All Inclusive Benefits (start day one)
• Student loan repayment, tuition reimbursement, FREE college education programs, retirement savings, paid paternity leave, fertility benefits, back up elder and childcare, pet insurance, PTO/Holidays, and more for full time and part time employees.