Essential Functions
- Accurate medical necessity screening and submission for Physician Advisor review
- Care coordination that includes admitting diagnosis/ medical history, current treatments, age, payment source, resources, support systems, anticipated needs, expected length of stay, appropriate level of service, special/ personal needs, and other relevant information.
- Assignment of initial DRG to determine GMLOS, while concurrently monitoring and managing LOS and transition planning as appropriate through assessment and reassessment and the application of InterQual guidelines.
- Leading and facilitating multi-disciplinary patient care conferences
- Managing concurrent disputes
- Making appropriate referrals to other departments
- Identifying and referring complex patients to Social Work Services
- Communicating with patients and families about the plan of care
- Leading and facilitating Complex Case Review
- Identification and documentation of potentially avoidable days
- Identification and reporting over and underutilization
- Ensures compliance with all regulatory standards including Federal, State, Local and Joint Commission with review requirements for Managed Contracts, Medicare, Medicaid, and Campus related to admission and continued stay approval.
- Adheres to Utilization Management Plan.
- Integrates National standards for care management scope of services including:
- Utilization Management supporting medical necessity and denial prevention
- Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
- Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and appropriate level of care
- Education provided to physicians, patients, families, and caregivers.
- Communicates appropriately and timely with the interdisciplinary team and third-party payers.
- Prioritizes activities in assigned areas to focus on high risk, high cost, and problem prone areas.
- Develops collaborative relationships with patient business, nursing, physicians, and patient/family to facilitate efficient movement through the continuum of care.
- Monitors and evaluates data, fiscal outcomes, and other relevant information to develop and implement strategies for improvement.
- Forwards identified quality and/or risk issues appropriately.
- Maintains positive relationships with outside/onsite reviewers and other payer representatives.
- Identifies cultural, socio-economic, religious, and other factors that may impact treatment.
- Involves patient’s family in the development of the treatment plan as appropriate while explaining procedures, therapies, systems treatment plans, and discharge plans in age/developmental/educational specific terms to patient/family.
- Reviews patient’s discharge plan at multidisciplinary meetings and/or staffing to facilitate communication with other healthcare team members.
- Prioritizes workload to manage multiple priorities while using problem-solving skills to meet goals.
- Enhances professional growth by participating in educational programs, current literature and/or workshops.
- Possesses excellent interpersonal skills and ability to work in a team environment.
- Respects the rights and privacy of others and holds staff member information in strict confidence.
- Maintains reasonably regular, punctual attendance consistent with Baptist Health policies, the ADA, FMLA and other federal, state and local standards.
- Maintains compliance with all Baptist Health policies and procedures.
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Other Related Functions
- Maintains records and documentation of work performed in an organized and easily retrievable fashion while maintaining confidentiality of data and patient information.
- Reviews current literature on a regular basis, maintains reference materials and updates as required, and keeps abreast of relevant reimbursement information.
- Actively serves on committees and task forces to promote quality, cost-effective care for patient population.
- Required skills include demonstrated organizational skills, excellent verbal and written communication skills, ability to lead and coordinate activities of a diverse group of people in a fast-paced environment, critical thinking and problem-solving skills and computer literacy.
- Performs other duties as assigned or required.
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