Clinical Operations Manager
6 days ago
Job Summary:
Las Palmas Medical Center is seeking a highly skilled and experienced Manager of Case Management RN to join our team. As a key member of our healthcare team, you will be responsible for providing overall coordination in the delivery of medical services and discharge planning for a specified patient population.
Key Responsibilities:
- Conduct concurrent and retrospective review of patient medical records for purposes of utilization review, compliance with requirements of external review agencies, and quality assurance agencies.
- Promote a cooperative and supportive relationship as liaison with patient, family, facility staff, physicians, funding representatives, and community agencies.
- Ensure continuity in the handoff of patient clinical information from the hospital to other involved healthcare entities.
- Communicate proactively and cooperatively with Patient Access, Patient Account Services (PAS), and Central Verification Office (CVO) personnel to ensure proper pre-certification and consistency of admissions status designation between physician order and EMR.
- Communicate known changes to patient payer information and other relevant financial characteristics of coverage to appropriate admissions and billing personnel.
- Proactively ensure that required clinical justification is provided to third-party payers to obtain recertification for continued hospitalization and treatment.
- Serve as a liaison between third-party payers, patient access, PAS, and CVO to ensure communication of all pertinent information regarding level of care, billing, and reimbursement.
- Work with the patient and family to identify alternate financial resources available to meet the cost of necessary post-discharge needs or to recommend alternate care options when necessary funding is unavailable.
- Proactively initiate an expedited appeals process with payers and communicate with denials management regarding anticipated or verified denials and cooperate with denials management to provide additional clinical information for appeals.
- Provide education to patient and family on case manager role and process for contacting the case manager for questions.
- Coordinate the integration of social services/case management functions into the patient care, discharge, and home planning processes with other hospital departments, external service organizations, agencies, and healthcare facilities.
- Collaborate with clinical staff in the development and execution of the plan of care and achievement of goals.
- Facilitate interdisciplinary patient care rounds and/or conferences to review treatment goals, optimize resource utilization, provide family education, and identify post-hospital needs.
- Ensure that patient tests are appropriate and necessary and are carried out within the established time frame and that results are promptly available.
- Serve as a patient advocate by enhancing a collaborative relationship to maximize the patient's and family's ability to make informed decisions.
- Refer to social work cases where patients and/or family would benefit from counseling required to complete complex discharge plans.
- Conducts concurrent medical record review using specific quality indicators and clinical decision support criteria as approved by the medical staff, TJC, CMS, and other regulatory agencies and document findings.
- Serve as liaison with Physician Performance Improvement (PPI) to ensure the reporting of quality indicators and care concerns.
- Initiate delivery of notices of non-coverage as appropriate.
- Review all new admissions daily against inpatient screening criteria and communicate necessary changes in status designation to ordering physician and Patient Access.
- Identify all observation patients with an observation alert sticker, reviews status no less frequently than daily, and communicate directly with the attending physician if severity of illness and intensity of service meet the criteria for inpatient admission or when observation hours threaten to exceed 48 hrs.
- Communicate with treating physicians at regular intervals throughout the hospitalization of the patient to develop an effective working relationship while assisting physicians to maintain appropriate costs, utilization of resources, and discharge plans commensurate with the patient's available resources.
- Ensure physician documentation supports medical necessity and LOC for each inpatient day, educate physicians by aggressively discussing additional documentation needs as identified or discharge plans, and confer with the Case Management Director and Physician Advisor as needed for intervention.
- Monitor and provide documentation of identified variance days for tracking and trending.
- Stay current with education related to CMS and HCA billing compliance mandates, and monitor and ensure that the facility is compliant.
- Facilitate the delivery of CMS discharge appeals rights communication to applicable Medicare patients within the indicated time frame required by law.
- Provide a retrospective chart review for short-stay inpatients under Medicare for medical necessity and level of care prior to billing.
- Collaborate with the interdisciplinary care team, service liaisons, patient, and family in the assessment and coordination of discharge planning needs, delivery of post-discharge services, and transition of the patient from an acute level of care to the discharge setting.
- Facilitate delivery of Patient Information and Choice Letter to assure documentation of patient/family involvement with discharge planning and choice of post-discharge service providers.
- Facilitate the ordering and delivery of specialized medical equipment, orthotics, and prosthetics as ordered by the attending physician.
- Facilitate the referral process of next level of care.
Requirements:
- RN licensure in the state of TX or Compact State.
- Associates Degree or BSN completion within 3 years of hire date.
- Prefer three-five years clinical experience within an acute healthcare setting with recent work history in acute care case management role or related healthcare experience.
- Working knowledge of case management philosophy/process/role, needs assessment, principles of utilization review/quality assurance, use of InterQual or other clinical decision support criteria, discharge planning, and reimbursement structures (i.e. Government and non-governmental payers).
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