Career Center

SUMMARY:

The individual in this position is responsible to facilitate and support an effective Utilization Review program within the Case Management department, which may be centralized within a specific market or group. The individual in this position has overall responsibility to ensure that care is provided at the appropriate level of care based on medical necessity and assess the patient for transition needs to promote timely throughput, safe discharge and prevent avoidable readmissions. This position manages medical necessity process for accurate and timely payment for services which may require negotiation with a payer on a case by case basis. This position integrates national standards for case management scope of services to include:

• Provides assistance to the Director of Case Management in the management of the Utilization Review/ Central Utilization Review department, but not limited to, hiring/training/managing staff, schedule coordination, analysis and reporting, interfacing, collaborating and working closely with the other departments.
• Accountable for compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy.

• Provides education to physicians, physician advisors, Case Management staff, and other hospital leaders as needed. Identify and provide physician education and feedback on hospital utilization and disputes/denials data.

• Review weekly Case Management Utilization Review (UR) and Continuing Care (CC) scorecards/metrics, Observed/Expected Length of Stay, Authorizations and Downgrades. Provides reports to DCM and hospital leadership as requested.
• Maintains knowledge of current contractual arrangements with Health Plans and Vendors. Partners with Managed Care representatives in JOC and other payer meetings to collaborate and communicate better outcomes.
• Organize the concurrent authorization process to meet utilization management needs and monitor turn-around times to meet health plan requirements. Implement and monitor processes to prevent payer disputes.
• Ensure medical necessity and revenue cycle processes are completed accurately and in compliance with Tenet policy as well as any state or federal program requirements.

The individual�s 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 underutilization, i) and other duties as assigned.

PHYSICAL DEMANDS:

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.

WORK ENVIRONMENT:

Individual works in a fast paced clinical and office environment.

TRAINING REQUIREMENTS

Must complete Tenet�s InterQual 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 hospital and department orientation is required. Department orientation includes review and instruction regarding Tenet Case Management and Compliance policies, InterQual®, Transition Management, Utilization Management, and other topics specific to case management.

PRIMARY INFORMATION, TOOLS AND SYSTEMS USED

• Patient data â�� hospital admission, discharge, transfer system
• Healthcare staff documentation related to patient care
• Regulatory and payor requirements

• Careport ®, MIDAS & other Care Management Documentation Systems
• McKesson Care Enhance Review Manager (CERMe) InterQual system

• Clinical data interface and secure faxing
• Patient Medical Record including Cerner, Mc Kesson, Meditech, EPIC and HPF
• Hospital specific Clinical Software

POSITION SPECIFIC RESPONSIBILITIES:

Department Operations

• Oversees an adequate number and skill mix of staff over seven days a week to serve the patient population and meet the goals of the department
• Supports and manages staffing requests utilizing the Tenet Case Management staffing recommendations within budgetary guidelines
• Plans and conducts regular departmental meetings with the Director to provide staff updates and ongoing education
• Assists the Director with the implementation of the InterQual Inter-rater Reliability (IRR) Policy to determine initial and yearly competency for all employees performing InterQual reviews

• Ensures new Case Management staff complete department orientation including review of Tenet Case Management and Compliance policies and Documentation training

• Assists the Director of Case Management in the management of the department, but not limited to, hiring/training/managing staff, schedule coordination, analysis and reporting, interfacing, collaborating and working closely with the other departments

• Monitors case management processes and staff productivity to ensure medical necessity reviews are completed timely and accurately, payer communications are sent and authorizations or denials documented and followed up, and that transition planning assessments are completed timely.

(30% daily, essential)

Utilization Management

• Monitors the review process to ensure medical necessity patients to be in the appropriate status and level of care per Tenet policy
• Balances clinical and financial requirements and resources in advocating for patient needs with judicious resource management
• Oversees submission of cases to Physician Advisor to ensure timely referral, follow up and documentation
• Monitors the timely communication clinical data to payers to support admission, level of care, length of stay and authorization for post-acute services

• Advocates for the patient and hospital with payers to secure appropriate payment for services rendered

• Participates in Revenue Cycle meeting, researching disputes, uncovering patterns/trends and educating hospital and medical staff on actionable items
• Implements and monitors physician â��peer to peerâ�� review process with payers to resolve denials or downgrades concurrently
• 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
• Utilizes data to provide timely and meaningful information to the Utilization Management Committee and physician staff for performance improvement.

• Balances clinical and financial requirements and resources in advocating for patient needs with judicious resource management

• Identifies and documents Avoidable Days using the data to address opportunities for improvement
• Prevents denials and disputes by communicating with payers and documenting relevant information
• Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay, discharge and post- acute care) compared to evidence-based practice, internal and external requirements.

(50% daily, essential)

Payer Authorization

• 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

(30% daily, essential)

Education

• Ensures and provides education to physicians and physician advisors 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
• May oversee work delegated to Utilization Review LVN/LPN and/or Authorization Coordinator.
• (10% daily, essential

Compliance

• 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.

• InterQual reviews completed accurately and timely
• Observation length of stay
• Excess Days/ALOS
• Clinical disputes - incidence and dollars
• Clinical Reviews & Authorizations
• Avoidable days
• Resource Utilization
• Position documentation and productivity

SUPERVISORY RESPONSIBILITIES:

Oversees staff assigned to the Utilization Review Staff within the Case Management Department, including, but not limited to, RN and LVN/LPN Case Managers and Authorization coordinators

QUALIFICATIONS:

Required qualifications include an active Registered Nurse license with at least two years acute hospital patient care, hospital case management, utilization review, healthcare, or leadership experience. B.S.N. preferred, ***unless higher degree required for Magnet Hospital Status. Accredited Case Manager (ACM) preferred. Acute hospital case management or supervisory experience preferred. Required skills include demonstrated organizational skills, excellent verbal and written communication skills, ability to lead and coordinate activities of a diverse group of people in a fast-paced environment, critical thinking and problem solving skills and computer literacy.

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.