Auth Coordinator - Case Manager RN

JOB SUMMARY

Authorization Coordinator collaborates with Insurance verification, insurance CM, Hospital Case Manager UR/transition Planner and physicians to facilitate obtaining authorizations. The individual's responsibilities include but are not limited to the following actions : a) Follow up on patient accounts when authorization for stay is required , Fax numbers to Send clinical reviews b) Follow up on each account during the stay and on discharge for authorization - document in the electronic system, c) Escalate any potential disputes or denial of accounts to Director of Case Management or designee d) Trends disputed e) Coordination of concurrent denials/preparation for appeal for retrospective denials f) other duties as assigned

DUTIES AND RESPONSIBILITIES

Essential Job Duties

• Validates patient's demographic and payer information with patient/family and notifies Patient Access immediately if any corrections are needed

• Validates that all commercial/managed care discharges have an authorization for status and level of care provided and notifies Director of Case Management (DCM) or designee of variances

• Cases that require authorization are obtained daily by fax or phone and documentation is completed daily

• Escalate discharged cases at end of day that have no authorization or notification of dispute is provided by payor

• Concurrently make sure all clinical needed by payors and updates are provided by alerting Case Manager assigned to case and escalating to DCM if not completed timely

• Trend dispute/denial potential to DCM or designee by failure points in revenue cycle

• Prepare denial information for UR Committee, Denial and Revenue Cycle Meetings

• Collaborate with Patient Access, Case Management, Managed Care and Business office to improve concurrent review process to avoid denial or process delays in billing accounts

• Adheres to 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

• Manages and operates equipment safely and correctly.

• Interacts professionally with patient/family and involves patient/family in the formation of the plan of care.

• Acts on performance improvement issues identified during CQI meetings.

• Actively participates in Case Management Committee, CQI, varying team meetings and other meetings, as appropriate.

• Maintains and respects confidentiality of patient/physician/personnel information.

• Demonstrates an ability to be flexible, organized and function under stressful situations.

• Maintains a good working relationship both within the department and with other departments.

• Consults other departments as appropriate to collaborate on patient care and performance improvement activities.

• Accurately determines type of assistance/setting/resources necessary for the patient/family and provides appropriate resources/assistance/list of facilities.

• Documentation meets current standards and policies.

PROFESSIONAL REQUIREMENTS

• Reports to work on time and as scheduled, completes work within designated time.

• Adheres to scheduling requests of the department (Works weekends, no "special days off", no exceptions, unless in school).

• Adheres to the Standards of Conduct of Baylor Scott and White at Sunnyvale while representing the organization in a positive and professional manner.

• Communicates the mission, ethics and goals of the facility, as well as the focus statement of the department and complies with all organizational policies regarding ethical business practices.

• Utilizes computerized punch time system correctly

• Completes annual education requirements and maintains regulatory requirements.

• Adheres to dress code, appearance is neat and clean and wears identification while on duty.

• Completes in-services and returns in a timely fashion and has not missed any mandatory in-services.

• Attends at least 8 staff meetings annually, is responsible for information presented at monthly staff meetings that he/she is unable to attend.

• Actively participates in performance improvement and continuous quality improvement (CQI) activities.

REGULATORY REQUIREMENTS

• RN with current Texas Nursing license
• 2 or more years with Medical Surgical Nursing experience -preferably Case Management experience

LANGUAGE SKILLS

• Able to communicate effectively in English, both verbally and in writing.

• Additional languages preferred.

SKILLS

• Basic computer knowledge.

PHYSICAL DEMANDS

• For physical demands of position, including vision, hearing, repetitive motion and environment, see following description.

2305051442