Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in health care facility to comply with government and insurance company reimbursement policies by performing the duties required through personally or through subordinate supervisors.
Reports to: CNO
Essential Functions
Evaluate each Inpatient and Outpatient case within 24 hours of admin to assure appropriate physician order and other documentation to support the appropriate level of care for the patient based upon criteria set for my CMS and by Commercial Insurance Companies.
Assure appropriate insurance authorizations as needed.
Work with Medical Staff to educate and facilitate required documentation to support the appropriate level of care for each patient, including participation in the Clinical Documentation Program.
Facilitate Discharge Planning through team collaboration for each patient that includes services required post discharge such as Home Health, Outpatient Therapies or skilled nursing care including Swing Beds and education regarding that care.
Documents actions taken to evaluate and facilitate the Case Mgt review and discharge planning.
Participate in statistical tracking and reporting of the Utilization Management metrics
Facilitates appeals of denials as needed, including analysis and corrective actions for denials due to those processes within the scope of the Case Management functions.
Organizational Expectations
Actively participates in Foundation Safety Behavior Tools and Tactics such as Briefs, Debriefs, Huddles, Learning Board Activities, Executive Patient Safety Rounds and reporting of unanticipated and unintended patient events regardless of whether there is a harm.
Provide effective mentoring
Be loyal to the absent
Always manage up
Consistent use of AIDET & 5 P's
Uphold the facilities Standards of Performance
Job Requirements
Minimum Education
Current RN license in the State of Tennessee
Required Skills
High level interpersonal skills to handle sensitive and confidential information. Position required ability to work with patients and families to achieve appropriate continuum care for the patient.
Certifications:
Basic Life Support (BLS) within 90 days of hire date.
Licenses: Current Tennessee RN license
Basic computer skills
Minimum Work Experience
2-4 years related experience and/or training.
Minimum of 5 years as a clinical nurse
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