Medical Review Coordinator
4 weeks ago
NYC Health + Hospitals/Metropolitan is a community hospital of choice for residents of East Harlem, northern Manhattan, and neighboring communities.
The hospital provides culturally-sensitive care in a welcoming and hospitable setting, emphasizing primary care medicine and utilizing the latest advances in medical science.
Metropolitan delivers high-quality health services with compassion, dignity, and respect to all, without exception.
Our mission is to deliver high-quality care health services, without exception.
Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.
Work Shifts
8:00 A.M - 4:00 P.M
Job Description
Key Responsibilities:
- Perform admission, continued stay, and discharge medical reviews using established criteria sets in an accurate and timely manner.
- Screen cases for post-discharge needs during admission review and communicate information to all disciplines as necessary and appropriate.
- Ensure that documentation in the medical record supports the plan of care and justifies the admission and continued stay. Communicate with physicians as necessary.
- Educate physicians regarding the appropriate InterQual/Milliman Guidelines to support the documentation of the plan of care.
- Establish a concurrent review cycle for each case on assigned clinical units based on medical need/status, medical plan, and resource utilization.
- Identify delays in service of treatment and actively interact with disciplines to remove barriers to care.
- Participate in Multidisciplinary Team Meetings to clarify issues, confirm plans of care, secure documentation required, and facilitate concurrent action.
- Communicate review findings to managed care organizations concurrently, to ensure compliance with contractual agreements according to departmental policy and procedure.
Alerts and Follow-ups:
- Alert physicians of concurrent, uncertified days in a timely manner and arrange MD-to-MD (Peer-to-Peer) Reconsiderations as appropriate.
- Request payor to send the resulting determination letter timely and follow up to ensure that the determination letter is received.
- Report any variances to the immediate supervisor and the denials Manager.
Minimum Qualifications:
- Graduate of an accredited Medical Program, including Foreign Medical Graduate; or
- New York State Professional Nursing Licensure (R.N.); and
- Two (2) years of experience in a hospital clinical setting in a capacity that provides a thorough understanding of medical diagnosis, symptoms, and treatment concepts; or one year of experience in Utilization/Quality Management; or a satisfactory equivalent.
Benefits:
- Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
- Retirement Savings and Pension Plans
- Loan Forgiveness Programs for eligible employees
- Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
- College tuition discounts and professional development opportunities
- Multiple employee discounts programs
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