Job Summary

Provides hospital case management/utilization review for patients seeking outpatient services for surgery and diagnostic procedures. Utilizes a team approach to promote continuity of care, problem solving skills and nursing processes to achieve optimal patient outcomes. Coordinates the integration of a multi-disciplinary approach to patient care. Coordinates hospital service concerned with outpatient case management and insurance follow up.

Adheres to departmental goals, objectives, and standards of performance, policies and procedures. Ensures compliance with quality patient care and regulatory compliance. Must possess strong communication and critical thinking skills, self-motivated and be able to work independently. Work collaboratively with members of the clinical team as well as representatives of insurance companies to achieve desired patient outcomes. Facilitates the provision of care and services needed to meet the patient’s needs in a timely manner.

Job Responsibilities

Essential Functions

• Justifies ordered services for diagnostics and surgery through external payer/insurance pre-certifications and concurrent reviews.
• Ensures proper documentation in EHR to support pre-certification requirements were met.
• Minimizes and informs patients of their financial responsibilities.
• Ensures compliance with payer rules and regulations.
• Consults with the Physicians for appropriate services and complete documentation.
• Manages with clinical resource usage for best financial and patient care outcomes for patient and FHN.
• Identifies and initiates referrals related to risk management, and quality of care issues to appropriate professionals, including medical staff quality issues.
• Reviews and provides documentation to appeal denials issued by insurance company.
• Assists the Physician offices with coordination of care for home services when necessary.
• Provides education and consults with Physician office on appropriateness of services ordered.
• Validates that all needs are addressed, referred, follow up on, and documented.
• Assists Provider’s with obtaining documentation of conditions, diagnoses, and procedures.
• Identifies appropriate CPT and ICD-10 codes needed to complete pre-certification and pre-determination.
• Provides patient education on insurance benefits and requirements.
• Communicates with providers, patients, and payers.

Special Skills and Abilities

• Utilize nursing process and crucial thinking skills into practice.
• Ability to access, plan, implement, coordinate, monitor and evaluate patient needs to promote quality and cost effective outcomes.
• Proficient computer and phone skills.
• Strong communication and negotiation skills to prevent denials.

Requirements

Education: Bachelor’s Degree in Nursing preferred

Required Experience: 2 – 5 years prior field related experience

Licensure/Certification/Registration: Accredited Case Manager Certification recommended

Physical Requirements:

Populations Served

While performing this job, the employee may care for patients in the following age groups.

• Young Adult (17 to < 30 years old)
• Middle Adult (30 years to < 60 years old)
• Older Adult (> 60 years old)
• No direct responsibility to treat or care for patients
• Serves patients in areas other than direct patient care

While performing this job, the employee does not care for patients in the following age groups.

• Neonate (< 30 days)
• Infant (< 1 year old)
• Early Childhood (1 year and < 5 years old)
• Late Childhood (5 years and < 13 years old)
• Adolescent (13 and < 17 years old)