Vail Health Case Manager 8020 in Vail, Colorado
Maximizes reimbursement for both patient and hospital through cooperation with third party payers and physicians. Follows up on denials based on resource utilization issues. Provides a smooth transition for the patient from hospital to home or alternative care setting through coordination of services to meet the post discharge needs identified while maintaining a balance among quality outcome, cost, and process. Identifies those patients with significant psychosocial needs and makes referrals to Social Services. Promotes continuous quality improvement by monitoring team processes as well as through communication with other teams impacted by or impacting the processes of this team.
Monitors for appropriateness of admission, continued stay, and readiness for discharge based on department defined guidelines and criteria as evidenced by appropriate documentation. Demonstrates utilization review accuracy using Interqual criteria.
Informs the patient and the attending physician when the patient doesn’t meet acute care criteria according to department criteria.
Cooperates with other departments in defense of denial of services by reviewing the chart for documentation of appropriateness of the admission/continued stay as evidenced by provision of supporting chart documentation.
Communicates with attending physicians when necessary.
Identifies the post-hospital equipment and unmet care needs of the inpatient and The Medicare patient (including observation) beginning within 24 hours of notification of admission as evidenced by placement of the completed discharge planning needs assessment form in the social service section of the chart.
Identifies the psychosocial needs of the patient and/or family and addresses those needs or make a referral to social services as appropriate as evidenced by documentation on the discharge planning needs assessment form.
Identifies the unmet financial needs of the patient and addresses those needs or make a referral to Inpatient Admissions Representative for HELP program or Social Services as appropriate.
Ensures that no services are denied for lack of clinical information when accurate contact numbers are received from Insurance Verification within the payer’s time-frame as evidenced by absence of denials which fall within the above guidelines.
Follows-up with patients within 14 days post-discharge where discharge planning referrals were made to identify the adequacy / flaws in the process.
Role models the principals of a Just Culture.
Perform other duties as assigned. Must be HIPAA compliant.
One year recent experience in acute care hospital Utilization Review, Discharge Planning or equivalent.
Two years experience in case management if incumbent is a Licensed Practical Nurse (LPN).
Licensed as a Registered Nurse in the state of Colorado or from a valid compact state OR licensed as a Licensed Practical Nurse in the state of Colorado required
Associates or Bachelor's degree in nursing.
Able to pass annual inter-rater reliability competency exam (IRR) with a score of 80%.