UM Reviews and Denial Support
- Perform InterQual Admission Assessments on all new admissions and forward the reviews to insurers as needed. Answer questions from the insurers and continue to provide any additional clinical information they request. Timely reviews to be provide so payers have sufficient time to review case and respond quickly.
- Communicate in real time with physicians on any patients not meeting criteria and establish a course of action.
- Work collaboratively with the MDs to help them understand documentation issues or any leveling issues or any leveling issues. Inform physician partners on Inpatient vs. Observation criteria or acute care criteria.
- Provide education to them regarding Inpatient vs. Observation criteria or daily care criteria.
- Act as liaison to managed care case managers for evaluating medical management of patients, referring questions to Medical Directors and/or payers when appropriate.
- Perform concurrent/daily InterQual reviews on assigned patients and document when InterQual criteria is not met.
- Forward all reviews to insurers on a timely basis.
- Answer any questions from insurers.
- Perform concurrent denial management to resolve issues prior to discharge of patient. Inform Directors/designee regarding outcome.
- Upon receipt of admitting or daily denials from insurers, review the case and provide the insurer with additional clinical information for the insurers reconsideration.
- Complete the clinical record and profile on a patient profile in Allscripts or a Steward designated software tool. Utilize the Allscripts tool appropriately so all fields are complete, all clinical information is fully recorded, all changes to a patients clinical condition is recorded, all interaction with insurers, RNs, MDs is documented, as appropriate.
- Copy the Allscripts clinical information and place in medial record, as appropriate.
- Finalize authorization for stay for all covered days prior to case closure
- The RN Care Coordinator provides resource 365 days per year.
- Rotate to other units of the Hospital including the ED as directed by the Care Coordinator Manager and the schedule for the Department.
- Rotation of holidays will be assigned as agreed under th Care Coordinator Model settlement.
- Rotation of weekends will be assigned based on each hospitals collective bargaining agreement and practice.
Discharge Planning and Execution:
- Review initial Admission Assessments and proposed discharge plans outlined by the SW Care Coordinator. Collaborate with SW Care Coordinator on discharge plan. .
- Identify the patients/discharges that may be complicated and review these discharges with the Social Worker.
- Coordinate and monitor discharge planning activities for an assigned patient population and provide support to the Social Workers and administrative staff managing the discharge process.
- Collaborate with the Interdisciplinary team to crate an individualized discharge plan for high risk patients, as needed ensuring appropriate level of services are scheduled for the patient.
- Inform PCPs, attending physicians and clinical staffs on alternative discharge options including high-tech home care, skilled nursing facility capabilities, and disease management initiatives in collaboration with SW Care Coordinators.
- Communicate pertinent patient information, on an as needed basis, with skilled nursing facilities, community health Agencies, physicians and other staff to insure all post-acute clinical information is provided.
- Information to be provided on a timely basis to not delay discharge.
- Obtain information from the CC Manager and CC Supervisor on Social Workers assignment and provide feedback, as needed, on SW assignments, priority of work and any follow-up issues.
- Be aware of disease management programs and services in existence within the Steward network to use network resources, as appropriate.
- Provide patient education and family teaching, on an as needed basis.
- Act as an advocate for the patient.
- Facilitate/coordinate multidisciplinary rounds on assigned patient care units, at a minimum of Monday-Friday.
- Attend UMCM meetings, as appropriate
- Maintain daily tracking tools, to support data reporting, including but not limited to the following list:
- Avoidable days
- Saved Days
- Interqual criteria
- Projected Discharge Date
- Payer issues
- Support the Care Coordination Manager/Director in maintaining the financial and clinical outcomes of the Care Coordination Department.
- Support the Steward physician network by coordinating with the Steward ambulatory/community care coordinators to ensure patient information is communicated and the transitions of care from inpatient to outpatient is planned and in place. This function will evolve over time as the community/ambulatory care coordinators are put in place.
- Identify opportunities to educate physicians on areas requiring documentation improvement and/or other improvements.
- Ensure that resources are managed in a cost-effective manner while achieving positive clinical outcome
- Identify service needs, systems issues and opportunities for improvement for the Department
- Review out-of-network referrals and scheduled procedures in order to manage the financial and utilization management of managed care contracts. Collaborate with the PCP and/or specialist to determine the possibility of redirecting care to/within the Steward network.
- Participate in the Hospital Quality Improvement Plan through unit and/or divisional quality control/quality improvement activities.
- Report deviations in quality care to the Manager/Director of Care Coordination.
- Assist with the development of clinical guidelines, as needed.
- Maintain current knowledge of regulatory requirements including changes to payer requirements, reporting and regulatory requirements.
- Demonstrate effective leadership skill
- Attend weekly Care Coordination meetings
- Complete all paper work required for regulations eg LTCF, OBRA, screening.
- Complete all Code 44 paperwork.
- Care Coordinator will be evaluated based upon clinical and financial criteria where they influence the outcome. Some of these criteria include but not limited to:
- Clinical denials
- Clinical denial back-log
- Outcome of clinical denials.
- Lengths of stay
- Timely patient discharges goal is 11:00am for patient discharge
- Full use of Allscripts, Meditech and InterQual.
- Full clinical reviews available in Allscipts
- Timely submission of clinical reviews to insurer
- Timely admission and concurrent reviews available for insurer
- Inter-rater reliability scores- performed routinely throughout the year.
- Demonstrated collaboration with Social Workers, CC Supervisor, CC Manager, physicians, residents and RNs on floor. This evaluation will be measured with feedback for other members of the care team
- Information for staff evaluations will be collected by Department and will be made available for performance reviews. Selected data will be provided by the Care Coordinator. Other data will be provided by CC Manager, Social Workers and the CC Reviewer.
Scope of Authority:
- Collaborate with Social Workers (SW) Care Coordinators on the units who will be responsible for the development and execution of patient discharge plans.
- Coordinate with SWs Care Coordinators for clinically difficult discharge plans.
- Review reports on the Departments performance including but not limited to - LOS, clinical denials and appeal status, avoidable days, time of discharge, proper level of documentation.
- Work with Care Coordination Manager/Director to develop educational needs and identify strategies to accomplish objectives of the Department.
- Given this job position is a new position; additional tasks may be added as the position is further developed. Changes to the job description shall be negotiated with the MNA to the extent required by the NLRA.
- Perform InterQual reviews on assigned patients and working with insurers to provide clinical information, answer questions, obtain insurance authorization for patients.
Management of Time and Resources:
- Completes work assignments within an acceptable time frame.
- Uses time and resources to the best possible advantage for successful completion of job responsibilities.
- Develops and maintains efficient working relationships.
- Is reliable in respect to attendance.
- Is Reliable in respect to punctuality.
- Recognizes the importance of team efforts and partners with others to achieve positive outcomes.
- Is part of a team effort to insure quality services.
- Offers creative solutions or alternatives to issues or concerns.
- Produces quality results.
- Continually strives to improve the quality of work.
Accepts responsibility for all work performed and takes appropriate corrective action as needed.