Serves as a Provider consultant in the coordination of care and utilization review process to determine legitimacy of admission, treatment, and length of stay in the hospital in order to comply with governmental and commercial insurance company reimbursement policies and procedures. Leads the unit care rounds and acts as resource and guide for multi-disciplinary team with efficient and appropriate utilization of resources. Analyzes patient records against insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, patient status, treatment, and length of stay of patients and confers with multi-disciplinary team, medical staff and nursing personnel to identify appropriate level of care, length of treatment and length of stay. Refers cases to Physician Advisor, leadership and facility Utilization Review Committee for review and course of action when case fails to meet admission standards.

NON-EXEMPT

Works in collaboration with Providers and multi-disciplinary departments within the hospital to facilitate the most appropriate and efficient utilization of services and coordination of care.

Must possess familiarity of utilization review processes and Center for Medicare and Medicaid Services rules and regulations for reimbursement.

Must possess understanding of the complexity of various insurances and asks appropriate questions to verify coverage.

Educates patients, families, physicians and hospital staff about level of care criteria and appropriate parameters for documenting severity of illness and intensity of care to be provided.

Collaborates with Transition Planners and multi-disciplinary medical team to insure a smooth patient transition between appropriate levels of care, designated facilities, and community care.

Must be able to achieve client (patient, family, and physician) satisfaction given decreased resources, and increasing limitations on hospital utilization.

Must understand the appropriate level of patient care for, but not limited to, the following patient population: Hospice/Palliative, Home Health, Transitional Care, Skilled Nursing, Rehab services, oxygen/medical equipment, and transportation needs.

Functions as a liaison between third party payors and responsible for effective public relations between hospital departments and community agencies.

Coordinators oversee all aspects of the utilization review process taking on many tasks including data collection, analysis, consulting and reporting.

Must perform other related duties and assigned tasks as requested, which may include: cross training and/or other job functions as temporary work loads and volumes require.

Must possess understanding of national health care trends and be able to analyze trends that impact the hospital and community settings.

Must assist in maintaining department records, reports, logs and files as required. Complete monthly statistical forms in a timely manner, if assigned.

Must participate in collecting data for process improvement as needed.

Assist Transition Planners with making initial contact with patient/family, get contact information, and discharge destination.

Document LACE tool within 2448 hours of admission.

Documents admission level of care reviews in Interqual within 24 hours of admission (Inpatients and Observation)

Leads Care Rounds reviewing the GMLOS current length of stay and identifying if patient is medically on track for discharge/transition to appropriate level of care.

Initiates care referrals in collaboration with Transition Planners indicated on all admissions.

Assists with discharge medication set-up/education and insurance.in collaboration with Transition Planner

Assists with clinical paperwork for Home Health Face to Face documentation and VAC dressings for wound care in collaboration with Transition Planner.

Assists with appropriate outpatient IV antibiotic set up/PICC or central line care/TPN/Enteral feeds in collaboration with Transition Planner.

Collaborates with Regional Care Navigator and sets up referrals with Regional facility, reports off to an RN as requested by facilities. Review all 30-90 day readmissions within 24-hours to identify reason for readmission.

Review transition/discharge "Live Well" binder and validates that all necessary discharge education has been completed and there is understanding on the patient/family's responsibilities in collaboration with nursing and multidisciplinary team membersObtains Mercy Flight pre-authorizations when appropriate

Collaborates with all Benefis System Navigators to insure smooth transition from Medical Stability to discharge.

Works with Transition Planning on a daily basis to insure information is shared and discharge/transition plan is moving forward smoothly.

Reports Avoidable days and delays in treatments, tests, etc. in Midas system and to Care Coordination Analyst for reporting.

Provides MCR letters to patients as required by CMS.

Provides Notice of Non-Coverage or HINN notices, Medicare Important Message and Observation letters, as appropriate.

Participates in Care Coordination and Utilization Review Huddles as scheduled.

Communicates with Physician Advisor for any situations requiring his/her intervention (i.e. denials, peer to peer reviews, complex cases, etc.)

Validates discharge education has been completed and medication scripts set up as appropriate in collaboration with nursing.

Inputs Condition Code 44, Occurrence Code 72, and OB Condition Codes as appropriate

Demonstrates the ability to deal with pressure to meet deadlines, to be accurate, and to handle constantly changing situations.

Demonstrates the ability to deal with a variety of people, deal with stressful situations, and handle conflict.

Professional Requirements:

Adheres to dress code.

Completes annual educational requirements.

Maintains regulatory requirements.

Wears identification while on duty.

Maintains confidentiality at all times.

Attends department staff meetings as required within the department.

Reports to work on time and as scheduled; completes work in designated time.

Represents the organization in a positive and professional manner.

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

Coordinates efforts in meeting regulatory compliance, federal, state and local regulations and standards

Communicates and complies with the Benefis Health System Mission, Vision and Values as well as the focus statement of the department.

Complies with Benefis Health System Organization Policies and Procedures.

Complies with Health and Safety Standards and Guidelines.