RN Case Review Coordinator
Performs the six essential activities of Case Management: Assessment, Planning, Implementation, Coordinate, Monitor and Reassess through the continuum of care to facilitate a safe cost-effective transition post discharge. Performs all aspects of audits and appeals including the peer to peer process. Perform utilization review to evaluate for appropriate level of care and faxes all insurance reviews timely to prevent denials. Collaborate with patient/family and interdisciplinary team to assess for appropriate discharge needs. Place and implement all aspects of referrals to all levels of post acute care in 4 Next. Online documentation of interaction with patient, family and interdisciplinary team. Interact with various third party payers on a daily basis. Fax clinical in payor communication to the right insurer with the right fax number in the right time frame. Refer cases not meeting appropriate level of care to the Physician Advisor or EHR. Review for Observation status and make changes as needed. Accurately facilitate all documentation needed for Medicare status change inpatient to observation (code 44). Perform and monitor for quality issues and document in R.L. solutions. Provide to the patient or family member a copy of the Important Message. Provide to the patient or representative the Observation Notification letter. Provide to the patient representative the Acknowledgement of disclosure ,obtain choices of post acute facilities or service and signature. Must be able to function independently in busy environment. Coordinate, complete and track all clinical denials and appeals.
SCHEDULE: 40 hours per week, Every other weekend.
ABOUT BRIGHAM AND WOMEN\'S FAULKNER HOSPITAL
Brigham and Women's Faulkner Hospital is a 162 bed non-profit, community teaching hospital located in Jamaica Plain directly across the street from the Arnold Arboretum. Founded in 1900, Brigham and Women's Faulkner Hospital has a long history of meeting the health care needs of our patients by offering comprehensive care in a wide variety of specialties. At Brigham and Women's Faulkner Hospital, our world revolves around our patients and their families, which is why weve been nationally recognized for our best practices in patient care, safety measures and surgical outcomes. If youre looking for more than a career, join Brigham and Womens Faulkner Hospital. Our patients call it better care. Our employees call it home.
Bachelors degree required. 3 year of Utilization Review and Case Management experience required, 4 years preferred. 5 years of Acute Care Nursing required, 6 years preferred. Current Registration as a Licensed Nurse in the State of Massachusetts. Staff adheres to all IC.A.R.E. Standards. Demonstrates knowledge, skills and abilities to work with various age groups in order to provide a safe discharge plan. Must be able to provide care for the patient despite psychosocial, education or physical disability. Basic computer skills, experience with excel ,word and good computation skills. Ability to interact and communicate within a diverse community. Competent with InterQual Criteria. Competent in Utilization Review, appeals, the peer to peer process and Case Management. Use critical thinking skills in all interactions and recognizes the need to be solution driven. Good negotiating skills with insurance companies and third party payers. Performs all aspects of discharge planning to the right environment of care, timely. Proficient in the use of ECare. Ability to work in a busy, fast paced environment. Push/pull up to 20 pounds.
Brigham and Womens Faulkner Hospital is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, national origin, protected veteran status, or on the basis of disability.