The individual in this position is responsible to facilitate effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care provided is at the appropriate level of care based on medical necessity. This position manages the medical necessity process for accurate and timely payment for services that may require negotiation with a payor on a case-by-case basis. This position integrates national standards for case management scope of services including:
- Utilization Management services supporting medical necessity and denial prevention
- Coordinating with payors to authorize appropriate level of care and length of stay for medically necessary services required for the patient
- Collaborating with Care Coordination by demonstrating efficient throughput while assuring care is sequenced and at the appropriate level of care
- Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
- Educating payors, physicians, hospital/office staff and ancillary departments related to covered services and administration of benefits and compliance
The individual’s responsibilities include the following activities:
a) Securing and documenting authorization for services from payors
b) Performing accurate medical necessity screening and timely submission for Physician Advisor reviews
c) Collaborating with payors, physicians, office staff and ancillary departments
d) Managing concurrent disputes
e) Identification and reporting over and underutilization
f) Timely, complete, and concise documentation in Tenet Case Management documentation system
g) Maintenance of accurate patient demographic and insurance information
h) Identification and documentation of potentially avoidable days
i) Other duties as assigned.
1. BSN preferred. At least two (2) years acute hospital or Behavioral Health patient care experience required. One (1) year hospital acute or behavioral health case management experience preferred.
2. Active and valid RN license required. Accredited Case Manager (ACM) preferred.