This new position will focus on initial and continued stay utilization reviews and denials management. This may include assessment of medical records for medical necessity and appropriateness in status assignment and/or level of care provided. A team approach with the facility Case Management team is critical. They will also provide clinical information to patient Insurance Plans according to the terms of the contract, receive authorization / certification for the stay, work concurrent denials, determine the correct patient status and communicate to the facilities, follow the X-Code process per HCA policy, maintain communication with the facility case managers, physicians and the Insurance Plans.
Some specific responsibilities include, but are not limited to:
- Validate the patient's status is correct (Inpatient vs Outpatient) based on physician's order, take action to correct status if incorrect or no order is present. Document actions.
- Perform admission reviews, on in scope populations, utilizing InterQual within 24 hours of admission.
- Perform initial admission clinical summary reviews within 24 hours or per payor contract on payors with an authorization process.
- Perform continued stay InterQual reviews a minimum of every other day on in scope populations.
- Perform continued stay clinical summary reviews as per payor contract on payors with an authorization process.
- Escalate cases not meeting criteria to Division PA
- Review and manage concurrent denials per FWD Centralized Utilization Review policy
- Follow X-Code process as per HCA policy.
- Communicate with physicians regarding patient status, level of care. Medical necessity, utilization of resources, and denials.
- Communicate lack of medical necessity and/or responder criteria being met to the facility Case Manager.
- Review the Certification / Authorization report daily to determine deficiencies.
- Documentation to take place, per HCA and FWD guidelines, in Midas in the Care Enhance Review Manager Enterprise (CERME), Midas Certification Entry, Midas Concurrent Review Entry and the Avoidable Denied Days module.
- Must be a graduate of an accredited nursing school and possess an active RN License
- A minimum of one year experience with InterQual is required
- A Bachelor's degree in Business, Nursing, or Healthcare Administration is preferred
- A Certification in Case Management is highly preferred, or willing pursue within one year (or when eligible)
- Acute care hospital experience is preferred
- Third Party Payor and Denial Management experience is a plus
Additional Skills Desired:
- Self-starter and independent worker.
- Excellent time management and problem solving-skills.
- Strong organizational skills and able to proactively prioritize needs and effectively manage resources.
- Ability to work within a Team.
- Excellent written and oral communication skills along with excellent interpersonal skills.
- Position requires candidates with determined and assertive communication skills.
- Must pass annual InterQual competency testing.
- Excellent personal computer skills (MS Outlook, MS Office, Midas, Meditech, OnBase DOS based and other related software).
A little about us:
HCA is the nation’s leading private provider of healthcare services. Comprised of locally managed facilities which include 230,000 employees at over 160 hospitals, over 120 surgery centers and 100 urgent care facilities in 20 states and the United Kingdom