The individual in this position is responsible to facilitate effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patientï¿½s resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity. This position integrates national standards for case management scope of services including:
Utilization Management services supporting medical necessity and denial prevention
Coordination with payers to authorize appropriate level of care and length of stay for medically necessary services required for the patient
Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
Education provided to payers, physicians, hospital/office staff and ancillary departments related to covered services and administration of benefits
The individualï¿½s responsibilities include the following activities: a) accurate medical necessity screening and submission for Physician Advisor review, b) securing and documenting authorization for services from payers, c) managing concurrent disputes, d) collaborating with payers, physicians, office staff and ancillary departments, e) timely, complete and concise documentation in the Tenet Case Management documentation system, f) maintenance of accurate patient demographic and insurance information, g) identification and documentation of potentially avoidable days, h) identification and reporting over and under-utilization, i) and other duties as assigned.
Required skills include demonstrated organizational skills, excellent verbal and written communication skills, ability to work in a fast paced environment, critical thinking and problem solving skills and computer literacy.
While performing the duties of this job, the employee is regularly required to sit, talk, and hear. The employee is frequently required to use fine motor skill (typing/data entry), and reach with hands and arms. The employee is frequently required to stand; walk; and occasionally stoop, kneel, or crawl. The employee must regularly lift and /or move up to 20 pounds and occasionally lift and/or move up to 50 pounds.
Individual works in a fast paced clinical and office environment.
PRIMARY INFORMATION, TOOLS AND SYSTEMS USED
Patient data ï¿½ hospital admission, discharge, transfer system
Healthcare staff documentation related to patient care
Regulatory and payor requirements
Allscripts ï¿½, MIDAS & other Care Management Documentation Systems
McKesson Care Enhance Review Manager (CERMe) InterQualï¿½ system
Clinical data interface and secure faxing
Patient Medical Record including Cerner, Mc Kesson, Meditech, EPIC and HPF
Hospital specific Clinical Software
Payor Specific Software
POSITION SPECIFIC RESPONSIBILITIES:
Balances clinical and financial requirements and resources in advocating for patient needs with judicious resource management
Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes
Completes and sends admission and concurrent reviews for payers with an authorization process identifies and documents Avoidable Days using the data to address opportunities for improvement
Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay and discharge) compared to evidence-based practice, internal and external requirements(60% daily, essential).
Assures the patient is in the appropriate status and level of care based on Medical Necessity and submits case for Secondary Physician review per Tenet policy
Ensures timely communication and documentation of clinical data to payers to support admission, level of care, length of stay and authorization
Advocates for the patient and hospital with payers to secure appropriate payment for services rendered
Prevents denials and disputes by communicating with payers and documenting relevant information
Manages payer dispute processes utilizing secondary review, peer to peer and payer type changes(25% daily, essential).
Ensures and provides education to physicians and the healthcare team relevant to the
Effective progression of care,
Appropriate level of care, and
Safe and timely patient transition
Provides healthcare team education regarding resources and benefits available to the patient along with the economic impact of care options
Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services
Adheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and Tenet policies
Operates within the RN scope of practice as defined by state licensing regulations
Remains current with Tenet Case Management practices(10% daily, essential).
PERFORMANCE METRICS AND EVALUATION
The metrics below provide an indication of the effectiveness of the individual in this role and may be used for evaluative purposes. The list below is not meant to be exhaustive; other relevant metrics may exist.
Medical Necessity reviews completed accurately and timely
Observation length of stay
Denial Write Offs-Commercial/Managed Care
Clinical Reviews & Authorizations
Position documentation and productivity
May oversee work delegated to Central Utilization Review LVN/LPN Case Manager and/or Central Utilization Authorization Coordinator
REQUIRED: An active Registered Nurse license with at least two years acute hospital or Behavioral Health patient care experience.
PREFERRED: BSN preferred (unless required * if Magnet Hospital). Accredited Case Manager (ACM) preferred. 2 years of RN Utilization Review experience.
Must complete Tenetï¿½s InterQualï¿½ education course within 30 days of hire (and at least annually thereafter) and pass with a score of 85 or better. Must complete and demonstrate competency in using the Tenet Case Management documentation system within 30 days of hire. Attendance at Central Authorization Team orientation is required. Orientation includes review and instruction regarding Tenet Case Management and Compliance policies, InterQualï¿½, Utilization Management, and other topics specific to case management.
Primary Location: Phoenix, Arizona
Facility: Abrazo Region
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Internal Number: 1905022087
About Abrazo Region
“Tenet Healthcare Corporation is a diversified healthcare services company with 115,000 employees united around a common mission: to help people live happier, healthier lives. Through its subsidiaries, partnerships and joint ventures, including United Surgical Partners International, the Company operates general acute care and specialty hospitals, ambulatory surgery centers, urgent care centers and other outpatient facilities. Tenet's Conifer Health Solutions subsidiary provides technology-enabled performance improvement and health management solutions to hospitals, health systems, integrated delivery networks, physician groups, self-insured organizations and health plans.