The position involves coordination of services to improve and maintain quality patient care and to ensure appropriate utilization of healthcare resources. Serves as a liaison between the hospital, providers, and external payers on issues related to intensity of service and severity of illness for patients. Ensures the timely and seamless transition of patients through medically appropriate levels of care. Conducts patient status and medical necessity reviews at the time of hospital admission and also concurrently throughout the stay. Reviews are documented in designated systems according to standard. In collaboration with physicians, promptly addresses documentation discrepancies. .
on medical necessity criteria. Participates in medical necessity audits. Assists with non-Medicare appeals research and preparation of written correspondence. Facilitates Medicare discharge appeal process through contracted Quality Improvement Organization (QIO). Participates in family care conferences as needed. Captures potentially avoidable days (PADs) and documents in designated system. Collaborates with physicians, nursing, social work, and other disciplines, departments, payers, and agencies to eliminate barriers to an efficient transition through the care continuum. Collaborates with discharge planning team, and assists in the facilitation of discharges as needed. Supports Population Health initiatives through patient outreach activities as assigned. Adheres to regulatory agency guidelines/requirements governing patient notification (ie Important Message from Medicare, Medicare Outpatient Observation Notice, Hospital-Issued Notice of Non-coverage). Complies with all SRH Policies and Procedures. Performs other duties as assigned by Manager or Designee.
EducationBSN required unless a Certified Case Manager (CCM), or 2 years equivalent experience.
Experience/TrainingMinimum three (3) years clinical practice experience required. Previous utilization review experience strongly desired. Experience using medical necessity screening criteria preferred.
License/CertificationCurrent Washington State RN License required. Certified Case Manager (CCM) or Certified Professional in Healthcare Management (CPHM) preferred.
Other QualificationsExcellent communication, organizational and interpersonal skills. Ability to work independently and manage time and decisions. Proficiency with standard software applications including spreadsheets and word processing. Knowledge of healthcare law and regulations related to acute care and the immediate post-acute continuum helpful.