As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

JOB SUMMARY

The Clinical Services Specialist is a member of the multi-disciplinary team that facilitates the patient's access to the appropriate level of care, health professional(s), and setting(s) to provide care and service(s) based on the patient's assessed needs and the hospital's capacity to provide the care. It is the Specialist�s responsibility to determine medical necessity. The individual in this position bears overall responsibility for coordinating patient care activities to conform to evidence-based practice and/or regulatory/payor requirements. This position integrates functions typically considered to be case management, care coordination and/or utilization management, and discharge planning assessment.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

• Coordinating care (e.g., access, admission, discharge, aftercare) in conjunction with physicians, nurse and other clinical staff, payors, patients and their families.
• Performing admission and continued stay review per policy and procedure.
• Planning for discharge needs and arrangements, including leading multi-disciplinary discharge planning teams and assessing patients for discharge planning needs.
• Reviewing utilization patterns.
• Establishes and maintains effective working relationships with representatives of managed care plans.
• Managing concurrent denials.
• Coordinating weekly Complex Case Review.
• Ensuring appropriateness of medical care provided and resources utilized compared to evidence-based practice and external requirements, including working with relevant systems and information such as InterQual, eCARE and ECIN.
• Staying abreast of relevant advances in medicine.
• Maintaining effective relationships with physicians, nurses and other clinical staff, payors, patients and their families.
• Assisting with physician documentation.
• Arranging for patient education.
• Communicating and collaborating with physicians, their office staff and staff of ancillary departments (e.g., lab, pharmacy).
• Maintaining accuracy of patient demographic and insurance information.
• Making the appropriate referrals to other departments (e.g., nutrition, PT/OT/ST).
• Complies with all policies & procedures that pertain to HIPAA including the minimum necessary requirements for this position.
• As part of the requirements for this position, the employee has access to the entire medical record for the purpose of coordinating care and planning for discharge needs and arrangements.
• Limits the protected health information (PHI) disclosed or requested to the amount reasonable necessary to achieve the purpose of the request. The disclosures or requests that occur on a routine basis include: patient demographics, condition, notification of actual/potential victim of abuse or neglect, description of injuries for the purposes of a crime investigation, actual/potential for organ donation & patient disposition updates.

Qualifications:

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Conversant knowledge and experience with case management care coordination, and/or utilization review

• Track record and comfort in collaborating with physicians

• Ability to lead and coordinate activities of a diverse group of people

• Demonstrated ability in problem solving and communications

• Working knowledge of and basic skills with computers

EDUCATION / EXPERIENCE

Include minimum education, technical training, and/or experience required to perform the job.

• Florida Registered Nurse license (R.N.) or Licensed Practical Nurse (L.P.N.) is required.

• Emergency Nursing and Case Management preferred.

• Three (3) years bedside experience in the relevant clinical specialty (e.g., care managers for pediatric patients should have pediatric nursing experience)

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Must be able to work in sitting position, use computer and answer telephone.
• Required to use fine motor skills (typing/data entry), and reach with hands and arms.
• Must be able to lift up to 25 lbs

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Subject to varying and unpredictable situations, many interruptions, multiple calls and inquiries, and change.
• May be required to work long hours and holidays.
  

Employment practices will not be influenced or affected by an applicant�s or employee�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.