This position will be responsible for addressing DNB’s, status mismatches, contact person for current Medicare/Medicaid RAC denials. Assist in gathering of clinical information and managing denials.
1. Coordinates internal and external services to avoid under or over utilization of resources.
2. Assess assignment of a working DRG in EPIC or other tools.
3. Facilitates or participates in interdisciplinary team meetings or rounds to assume appropriate level care and resource utilization.
4. Reviews & assesses medical record for appropriate physician orders and documents admission, concurrent discharge reviews and retrospective reviews as assigned.
5. Consults with physicians regarding the appropriate level of care or admission status when criteria are not met for correct level of care for inpatient, observation or continued stay.
6. Refers cases to Physician Advisor or other secondary review service according to policy and documents the referral.
7. Reviews Observation status patients as soon as possible but within 48 hours of admission and obtains appropriate orders based on patients’ clinical condition.
8. Notifies admissions office of errors/changes in patient data including changes in physician orders/incorrect admission status designation.
9. Collect, identifies and documents avoidable days, authorizations and denials.
10. Reviews work queues for clinical and technical denials through strong follow-up and appeal process for designated payors.
11. Reviews DNB and event management work queues to address appropriate admission status based on medical necessity.
12. Provides technical and clinical information to the Utilization Management team to support the reduction in denials.
13. Tracks and trends denials and reports results to Utilization Management leadership.
1.Participation in Lean/transformational care teams to improve functional process as it relates to improvement across the organization.
2.Responsible for tracking and reporting monthly and quarterly reporting of all CMS required reports – Condition 44, Appeals, IMM, OBS Letters, PA Referrals, denials, etc.).
3.Responsible for ongoing education and mentoring of all providers including staff on InterQual and tracking consistency in application of criteria using monthly chart audits and bi-annual inter-rater reliability testing.
4. Evaluate & assess clinical documentation to support medical necessity for RAC denial team to appropriately prepare medical record for submission and review for potential overturn and recovery reimbursement of dollars for care provided.
5. Participation on Revenue cycle and Denial Management committees with reporting structure to Director of CM, Director of Revenue cycle, and CFO.
This position does not provide patient care.