Summary

Job Description

Provides overall coordination in the delivery of medical services and discharge planning for a specified patient population. Performs concurrent review of patient medical records for purposes of utilization review, compliance with requirements of external review agencies including governmental and non-governmental payers and quality assurance agencies. Promotes a cooperative and supportive relationship as liaison with patient, family, facility staff, physicians, funding representatives and community agencies. Ensures continuity in the handoff of patient clinical information from the hospital to other involved healthcare entities.

Duties And Responsibilities

• Screens calls for admissions against Milliman Care Guidelines (MCG) to determine if member required Observation admissions vs Inpatient admission to the acute care setting. Process inpatient denial and approving observation efficiently.
• Facilitates patient’s transfer to contracted hospital when admitted to an out of network and needs continued hospitalization within 24 hours of admission. The nurse follows the Out of Network Transfer Protocol and documents the specific reason/s why patient is not repatriated back into network or capped facility. (Non-repatriation codes)
• Facilitates Emergency Room (ER) transfers when patients require admission. The nurse assesses and verifies if the patient is stable for transfer if stable will proceed to Step 1a. If unstable or no bed is available, the nurse gives authorization to admit the patient. Coordinates transfers of patients for higher level of care (tertiary, quaternary)
• Verifies if the attending physician assigned on the case is the contracted hospitalist. If assigned attending is not the correct hospitalist, the nurse switches the providers by calling the contracted hospitalist on the case, once accepted, the nurse informs the attending provider that IPA contracted hospitalist will be taking over the case.
• Calls the hospital UR Department, SNF CM or hospitalist to request initial reviews, concurrent reviews, and discharge needs. Documents daily clinical reviews in the EZ-cap system and assigns the appropriate Level of Care (LOC) and approves the authorization if deemed medically necessary using MCG or Health Plan required guidelines.
• Identifies potential CCS cases (contracted CCS hospital/provider), obtaining the SAR, referring cases to CCS
• Identifies unnecessary or aberrant days and forwards the information to the Medical Director for final review and determination of potential denial of days. Forwards the case to the Notice of Action (NOA) Coordinator for denial or modification letter generation. The nurse ensures that the case is closed accurately, and documents ADMIT TYPE, ADMIT SOURCE, PATIENT STATUS on the Auth Details Field within the required ICE TAT.
• Coordinates discharge needs and provides authorization i.e., home health care PT, OT, skilled nursing visits, home infusion, Self-injectable drugs, DME, medical supplies, etc.
• Forwards to Realignment team/ Member Liaisons information of SNF patient who is admitted to long-term care and has resided in a nursing facility beyond 30 days after the month of admission to facilitate disenrollment of member from managed Care Medical back to Fee for Service Medi-cal.
• Attends the daily inpatient meeting to go over daily bed day reports with the Medical Directors.
• Refers potential readmissions to Outpatient High Risk Case Management (SPD, SNP, CMC) or Readmission Teammates (non-SPD, non-SNP, non-CMC) for follow-up post discharge. Refers any potential quality of care issues (PQI) identified to the QI Department for review of QI cases.
• Provides coverage as needed.
  
  

Minimum Job Requirements

• Current RN or LVN licensure; Preferred: BSN level of education.
• Working knowledge of case management philosophy/process/role, needs assessment, principles of utilization review/quality assurance, use of Milliman or other clinical decision support criteria, discharge planning, and reimbursement structures (i.e. Government and non-governmental payers).
• Ability to read, analyze and comprehend complex clinical data and its application to level of care criteria and discharge options; strong, broad-based clinical knowledge and understanding of pathology/physiology of disease processes; excellent critical thinking skills; assertive personality traits to facilitate ongoing physician communication; organize, prioritize and manage time efficiently.