Primary Purpose
Assists and collaborates with multidisciplinary team in providing specific clinical information that meets expectations of third-party payors; responsible for timely provision/flow of clinical information to/from third party payor and multidisciplinary team to ensure certification/approval of inpatient services. Provides clinical expertise/knowledge support to the payor specialist(s). Reviews clinical information prior to sending to payor as needed to ensure information meets acute clinical care guidelines.
• Identifies clinical, financial, and psychosocial needs of patients/families and provides leadership and guidance to the multidisciplinary team to develop an individualized plan of care.
• Ensures essential information and necessary forms are placed in the revenue cycle tool and available for the revenue cycle team and other disciplines.
• Provides necessary documentation and information to third party administrators as needed.
• Performs admission and concurrent reviews.
• Applies clinical guidelines during Admission and Concurrent reviews and identifies potential third-party denials. Works with multidisciplinary team to identify and implement alternative plans of care.
• Initiates and request authorizations for post-acute care as needed to facilitate care coordination.
• Refers pertinent cases to the Medical Director, Service Director, and/or Physician Advisor in a timely manner.
• Collaborates as needed with the physician to plan and implement medical and multidisciplinary plan(s) of care, utilizing clinical pathways when appropriate and available.
• Identify and escalate barriers and problems to the multidisciplinary team and leadership for intervention and resolution.
• Develops and maintains accurate case records of assigned cases. Documents in the patient's medical record according to department and facility standards.
Minimum Job Requirements
Education
Graduation from an accredited School of Nursing required. Bachelor’s degree in nursing preferred. NC RN licensure required. Related experience preferred
Certification / License
Basic Life Support (BLS) for Healthcare Provider (HCP) per facility requirements
Physical Requirements and Working Conditions
Works in an office setting, extensive walking throughout the facility. Prolonged periods of sitting reviewing medical records and documentation. Repetitive wrist motion and occasional lifting of 10-20 pounds. Requires frequent verbal and written communication in English. Intact sight and hearing with or without assistive devices are required.
DISCLAIMER
All responsibilities and requirements are subject to possible modification to reasonably accommodate individuals with disabilities.
This job description in no way states or implies that these are the only responsibilities to be performed by an employee occupying this job or position. Employees must follow any other job-related instructions and perform any other job-related duties requested by their leaders.