Work Schedule Details:
Position requires 10h/shift on alternating w/e (2 full weekends per month) and 8h shift per week x 3, totaling 64 hrs. per month.
Duties & Responsibilities:
- Validates authorization for all bedded patients.
- Validates commercial payer authorization within the contractual timeframe at time of presentation, every third day or as needed ( e.g. ED, Direct Admit, Transfers).
- Manage concurrent cases to resolution care that may impact payer approval to authorize care as medically necessary Partner with Revenue Cycle team to support resolution of retrospective denials.
- Coordination of review with third party reviewers.
- Manage retrospective review process. Conducts initial review and continued stay reviews as designated in UM plan.
- Reviews records for medical necessity and collaborates with physician (s) and members of the care team to validate information.
- Establishes and communicates estimated LOS using GMLOS.
- Utilizes InterQual Level of Care Criteria as a guide to support medical necessity determinations.
- Refers cases with failed criteria to Physician Advisor and appeals as necessary.
- Collaborates withCM, SW, Physicians, and Care Team to enhance communication related to discharge planning and utilization management.
- Ongoing collaboration with Case Manager to ensure that patient?s condition meets medical necessity criteria and communicate changes that could affect the discharge plan of care.
- Confirms that orders reflect the patient?s level of care utilizing established criteria.
- Partners with internal and external Physician Advisors, as well as Compliance and with Revenue Cycle partners, within the health system to provide a safeguard processes and expected outcomes.
- Provides formal and informal education to physicians and the healthcare team to improve processes and outcomes related to utilization review and compliance with utilization management plan.
- Provides feedback as requested to enhance negotiations with payors.
- Develops and maintains positive relationships with customers internal and external to Duke Health System.
- Maintains effective communication with health care team members related to care coordination and utilization management.
- Contributes to a positive working environment and performs other duties as assigned/directed to enhance the overall efforts for the organization. Actively participates in a hospital committee
- Works collaboratively with physicians, staff and service line leadership on quality and performance improvement activities related to optimal utilization of resources, efficient delivery of high quality care, patient flow, capacity management and other clinical cost reduction initiatives.
Requisition Number 101001142
Duke Entity DUKE REGIONAL HOSPITAL
Job Code 5013 CASE MANAGER
Job Family Level G1
Full Time / Part Time PRN
Regular / Temporary Regular
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BSN or MSW required
3 years of relevant experience
Degrees, Licensures, Certifications
Requires ACM or CCM certification within 3 years of hire or by December 31, 2017 for current employee. BSN must have current or compact RN licensure in the state of North Carolina. MSW must have a current North Carolina license as a CMSW within 90 days of hire or a current license as an LCSW.
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