The individual in this position works under direction of RN Case Manager and/or Social Worker. The individualï¿½s 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 claims by at least payor and physician e) assist in obtaining authorization for patient discharged to Skilled Facilities or other post-acute care that require authorization f) other duties as assigned.
Skills required include excellent organizational skills, excellent verbal and written communication skills, demonstrated problem solving skills, and computer literacy. Data Analytic skills preferred.
While performing the duties of this job, the employee is regularly required to sit, talk, and hear. The employee is frequently required to use fine motor skill (typing/data entry), and reach with hands and arms. The employee is frequently required to stand; walk; and occasionally stoop, kneel, or crawl. The employee must regularly lift and /or move up to 20 pounds and occasionally lift and/or move up to 50 pounds.
Individual works in fast paced clinical and office environment.
Attendance at hospital and department orientation is required. Department orientation includes review and instruction regarding Tenet Case Management and Compliance policies, Tenet Case Management documentation and referral system and clerical support duties specific to case management.
PRIMARY INFORMATION, TOOLS AND SYSTEMS USED
Patient data ï¿½ hospital admission, discharge, transfer system
Healthcare staff documentation related to patient care
Regulatory and payor requirements
Allscripts ï¿½ Care Management System
MIDAS Case Management documentation system
Clinical data interface and secure faxing
Patient Medical Record including Cerner, Meditech, EPIC HPF and other Medical Record systems
Hospital specific Clinical Software
POSITION SPECIFIC RESPONSIBILITIES:
Validates patientï¿½s 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(85% daily, essential).
Follow up on Authorization for post-acute services
Makes referrals for post-acute services under the direction of the RN Case Manager or Social Work (SW) staff utilizing the Tenet Case Management documentation system
Follow-up if referral requires an authorization by payor to discharge the patient
Completes tasks as assigned by RN or LVN Case Manager and/or SW staff
Makes copies, send faxes and complete phone calls to arrange post-acute services and to ensure that appropriate hospital information is communicated to post-acute providers
Documents all referrals and tasks in the Tenet Case Management documentation system per Tenet policy
Provides Important Message follow up letter to Medicare beneficiaries per Tenet policy and under the direction of the RN Case Manager or SW(10ï¿½ily, essential).
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 and Tenet policies(5% daily, essential).
PERFORMANCE METRICS AND EVALUATION
The metrics below provide an indication of the effectiveness of the individual in this role and may be used for evaluative purposes. The list below is not meant to be exhaustive; other relevant metrics may exist.
Clinical disputes - incidence and dollars
Number and type of avoidable days
Position documentation and productivity
Required: High School diploma or equivalent required.
Preferred: Associate or Bachelorï¿½s degree preferred. Paramedic, EMT or Nursing Assistant certification preferred. Acute hospital experience preferred.
Primary Location: Phoenix, Arizona
Facility: Abrazo Region
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Internal Number: 1905029388
About Abrazo Region
“Tenet Healthcare Corporation is a diversified healthcare services company with 115,000 employees united around a common mission: to help people live happier, healthier lives. Through its subsidiaries, partnerships and joint ventures, including United Surgical Partners International, the Company operates general acute care and specialty hospitals, ambulatory surgery centers, urgent care centers and other outpatient facilities. Tenet's Conifer Health Solutions subsidiary provides technology-enabled performance improvement and health management solutions to hospitals, health systems, integrated delivery networks, physician groups, self-insured organizations and health plans.