Lead Clinical Nurse Reviewer-Case Management-Phoenix

Phoenix Children's Hospital Phoenix , AZ 85002

Posted 1 week ago

Position Details

Department: Case Management

Category: Care Mgmt/Social Wrk/Case Mgr

Location: Phoenix

Posting #: 530917

Date Posted: 10/9/2020

Employee Type: Regular

Position Summary

Posting Note: This Lead role has the option of working 4/10's or 8/5's M-F. Location: 1919 East Thomas Rd., Phoenix, AZ 85016

The position provides comprehensive assessment, coordination, implementation and reporting of complex clinical data. This position audits medical records on behalf of hospital clients for denials review, defense audits, disallowed charges and ongoing insurance reviews. Develops, implements, monitors and documents the utilization of resources and progress of the patient throughout the continuum of acute care. Advocates and facilitates options and services to meet the patient`s health care needs. Assists the Manager,Case Management, with the daily operational activities by monitoring quality and effectiveness of workflow, problem resolution and troubleshooting issues, and processes to ensure optimum efficiency and compliance with all regulatory licensing requirements. This position may supervise Utilization Management staff on an adhoc basis as directed by the Manager,Case Management. This position works independently receiving supervision of work activities from the Manager,Case Mgmt.

PCH Values

  • Family-Centered care that focuses on the need of the child first and values the family as an important member of the care team

  • Excellence in clinical care, service and communication

  • Collaborative within our institution and with others who share our mission and goals

  • Leadership that set the standard for pediatric health care today and innovations of the future

  • Accountability to our patients, community and each other for providing the best in the most cost-effective way.

Position Duties

  • Leadership

  • Provides guidance, mentoring, and direction as appropriate for ongoing staff development.

  • With the Medical Director of Utilization Management and the Care Management leadership team plans, recommends, organizes and implements approved protocols, policies, and guidelines for the Utilization Management Program and supports overall organizational values and mission.

  • Participates in hospital and departmental operational initiatives to evaluate and improve reimbursement, denials, level of care and goal length of stay.

  • Coordinates work activities of assigned staff to ensure achievement of established goals, objectives, and outcomes.

  • Collaborates with Lead Case Manager, Case Management Manager, Care Management Director and Utilization Medical Director.

  • Leads employees through ongoing goal setting, training and performance feedback.

  • Evaluates performance of Utilization Management technician and assists in completing performance appraisals.

  • Provides team leadership, demonstrates strong, consistent clear communication and serves as central point of information informing all team members.

  • Cultivates and maintains effective interaction/communication with members of the interdisciplinary team, Case Manager/Utilization Teams to drive the care coordination process and to facilitate continuity of patient care.

  • Utilization Management

  • Manages Utilization Management processes to achieve effective management of goal length of stay and resource utilization in a manner that promotes sound financial stewardship as well as patient-family advocacy.

  • Completes ongoing insurance reviews utilizing MCG criteria to identify needs related to admission and continued stay.

  • Leveraging MCG evidence-based guidelines, coordinates, development and implementation of a comprehensive plan in collaboration with the Case Management Team.

  • Proactively collaborates with members of the interdisciplinary clinical care team to define and document a clear and comprehensive treatment plan. Identifies and facilitates resolution of variances in the plan of care that may impact goal length of stay.

  • Facilitates and provides on-going communication with Utilization Management/Care Management Teams, escalates unresolved barriers to timely discharge to Case Manager, Manager of Case Management and Utilization Management Medical Director, as per department protocols.

  • Reviews and analyzes denials received in the Utilization Management Department and communicates to Case Manager, Manager of Case Management and Utilization Management Medical Director, as per department protocols.

  • Cultivates and maintains effective interaction/communication with members of the interdisciplinary team.

  • Reviews the patient reports daily for appropriate level of care, goal length of stay as per MCG criteria and communicates with assigned unit Case Manager.

  • Assesses each patients status as appropriate to patient needs. Ensures timeliness of care and identifies barriers to transition of care or discharge.

  • Communicates with Utilization Management Leadership denials requiring a physician to physician conversation.

  • Attends insurance meetings with Utilization Management Medical Director and Care Management leadership as needed.

  • Attends Denial Committee meetings with Hospital Revenue Cycle/ Physician Revenue Cycle as needed.

  • Attends Utilization Management meetings with Utilization Management Medical Director and Care Management leadership as needed.

  • Develops collaborative health care team

  • Collaborates with interdisciplinary team on level of care, goal length of stay, identified barriers, and other issues that may impact reimbursement.

  • Establishes a collaborative relationship with Hospital Revenue Cycle management and staff, and community providers. Mentors internal members of the health care team on utilization management.

  • Identifies from review of documentation opportunities for ongoing education with physicians and the health care team.

  • This position performs onsite job duties and responsibilities at Phoenix Children`s Hospital, and is viewed as an accessible member of the health care team.

  • Participates in monthly department process improvement meetings.

  • Regulatory Responsibilities

  • Monitors performance of Utilization Management process in accordance with all state mandate regulations, understands and focuses on key performance indicators and promptly reports potential denials to Case Management Team.

  • Working knowledge of DRG payment methodology and ICD9/ICD-10 coding system.

  • Financial Accountability

  • Utilizes MCG criteria to determine admission status, level of care, goal length of stay and continued provision of services.

  • Communicates with payers to resolve potential denials.

  • Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct ongoing insurance reviews.

  • Manages optimal outcomes to promote high quality of care in the most cost-effective manner and appropriate setting.

  • Participates in various aspects of the hospital revenue- cycle by documenting in patient and financial account systems any avoidable days, extended length of stay, authorizations, request of next review due, denials and rescinded days for medical necessity.

  • Consults with social services and other resources as needs or problems are identified.

  • Completes monthly documentation and financial audits as requested by department manager and director.

  • Provides ongoing management of denial and appeal with Hospital Revenue Cycle Department and the Nurse Auditor. Reports trends to Care Management and Utilization Leadership.

  • Manages in collaboration with Case Managers denials attributed to medical necessity, appropriate level of care or extended length of stay. Communicates and documents potential denials and non-certified days in EMR and financial applications.

  • Provides excellent customer service

  • Establishes a collaborative relationship with interdisciplinary team, community providers and Hospital Revenue Cycle management and staff.

  • Provides excellent service routinely in interactions with all customers, i.e. coworkers, patients, visitors, physicians, volunteers, etc.

  • Responds to emails within 24 hours.

  • Clear communication skills with all internal and external customers.

  • Performs miscellaneous job related duties as requested.

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