South Lake Hospital is centrally located in Clermont, Florida, which combines the appeal of suburban life with easy access to Orlando, all of the major theme parks, and beautiful beaches on both coasts. At South Lake Hospital, our mission is to improve the health and quality of life of the individuals and communities in South Lake County. Our 160-acre health, wellness, and education campus provides a complete continuum of quality care. With 170 beds, and more than 1,500 employees, we offer a variety of medical services including diagnostic imaging, orthopedics, robotic surgery, urology, women's services, and our cardiac catheterization laboratory.
Responsible for ensuring an efficient, cost effective care management process by determining the patient's medical necessity and financial liability through the coordination of insurance reviews and issuance of authorization numbers through submission of required clinical information.
* Guides the care managers in the performance of medical record reviews for medical necessity of admission and the placement of the patient in appropriate bed status.
* Works directly with the Care Management department, the Business Office, Patient Access, and along with the Hospital's Revenue Cycle to ensure quality and efficiency of certain elements of claims processing, denial prevention, and denial management.
* Retrieves designated reports from Allscripts Care Management and other systems in an effort to identify, organize, prioritize, and validate the requests for pre-authorizations and/or authorizations have been obtained or that appropriate, timely follow-up has been completed.
* Responds to internal and external inquires in person, through telephone calls, or electronically, routing calls to appropriate individuals.
* Retrieves and disseminates face sheets, consultation requests, clinical, and other information, as deemed necessary, to appropriate individual(s) in a timely manner.
* Submits/faxes required/ requested clinical information to insurance company for authorization of patient hospitalization.
* Coordinates insurance company requests and authorization numbers with the care managers and Patient Access Department.
* Enters authorization numbers and appropriate payer documentation/correspondence into the Allscripts system.
* Completes retrospective reviews utilizing the daily discharge list to validate that all patients had an initial medical necessity review completed and the outcome is favorable for reimbursement of the designated bed status. If an initial admission medical necessity was not completed, the Care Manager, Senior will assign the review to be completed by a unit Care Manager, or will complete the review. Note: These retrospective reviews are time sensitive, due to the coding and billing guidelines and need to be completed within 3 days of the patient's discharge. Any discrepancy needs to reconciled immediately and/or notification of the appropriate HIM or Business Office Staff to "pend" the account.
* Completes retrospective medical necessity review for all readmitted patients within 30 days to identify if there is any quality of care and/or premature discharge. If a quality of care issue is identified and the patient's readmission may be directly related to the a failure of the treatment or discharge, discuss findings with the Physician Advisor and coordinate the processing and billing of these two admissions as one DRG. If no quality of care or failure of treatment or discharge plan is identified, coordinate with the business to prepare each account for a separate DRG payment.
* Assist in appealing existing denials by communicating necessary information to the payers.
* Assists in denial prevention by proactively communicating with care management staff, the bedside nurses, physicians and the Physician Advisor in obtaining pertinent information. Also actively assists with the request by the payer(s) for Peer-to Peer reviews.
* Demonstrates the knowledge and skills necessary to provide appropriate care in consideration of the growth development, and social needs of pediatric, adolescent, adult, and geriatric patients.
* Enhances professional growth and development through participation in educational programs, current literature, in-services, meetings, and workshops.
* Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards.
* Maintains compliance with all Orlando Health policies and procedures.
Other Related Functions
* Assists Business Office personnel in preparing appropriate documentation relating to the admission, denials and appeals process.
* Communicates with the payer(s) to facilitate covered-day reimbursement authorization for assigned patients. Discusses payer criteria and issues on a case-by-case basis with pertinent clinical staff and follow-ups timely to resolve issues with payers to avoid denials or reimbursement penalties as well as any medical necessity determinations which may result in patient liability.
* Escalates cases to the Physician Advisor when the patient is not satisfying criteria and/or a quality of care concern is identified.
* Assists Care Manager to identify patient with barriers to discharge as well as patient with a high risk of readmission and communicate to payer and Care Management Team.
* Discusses High Risk Length of Stay patients or complex patients/situations that documentation is supporting the LOS and the concurrent stay criteria are met or to assist in expediting the discharge/transfer to a lower level of care.
* Review payer requirements and government regulations to ensure compliant, safe, healthcare.
* Assigns tasks to care management assistant and appropriate referrals to SW Care Coordinator to reach desired treatment outcomes.
* Interprets problems and selects appropriate solutions based upon similar situations that have occurred in the past.
* Plans events that are expected to occur from one to four weeks, or on a monthly basis.
* Regularly contacts employees to discuss issues of moderate importance and to respond to inquiries. Occasionally requires contacts with employees at higher levels on matters requiring cooperation, explanation and persuasion.
* Requires regular external contacts to discuss issues of moderate importance and to respond to inquiries. Also requires ongoing personal contact with the public involving matters requiring cooperation, explanation and persuasion.
* Requires extensive knowledge of their professional discipline and a working knowledge of related fields. Understands information in several unrelated professional disciplines.
Bachelor's degree in a healthcare related field.
Maintains current license as a Registered Nurse (RN) in Florida.
Certification as an InterQual trainer within six (6) months from date of hire.
Five (5) years of acute clinical experience to include at least two (2) years in utilization management.
Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled