This position assists the Department of Case Management with assigning patients to the appropriate level of care, maintaining compliance with Medicares Conditions of Participation, and obtaining appropriate reimbursement from payers by performing the following functions:
Conducts admission reviews using InterQual criteria when at all possible before admission, but at a minimum of within 24 hours of admission.
Monitors Observation patients stay within the hospital every four hours, noting changes in clinical status and taking appropriate action.
Coordinates the care, discharge, or admission to inpatient status, for observation patients.
Assures that Observation patients care, diagnostic testing, and laboratory work is performed in a timely manner and within the 24-48 hour guidelines.
Assures that patients are assigned the appropriate status in PBAR.
Conducts reviews of one-day-stays and other outlier cases as identified by the UR Committee and the Director of Case Management.
Works collaboratively with Health Information Services and Patient Business Services to assure compliance with Medicare guidelines regarding billing claims.
Documents total hours of billable observation hours in PBAR.
Communicates directly with the admitting physician and/or Emergency Department physician when a patients ordered admission status is inappropriate, using InterQual as a guide, and informs physician of same, obtains the necessary clinical data to justify the admission, or resolves the by obtaining appropriate physician orders whenever possible.
Consults with the Physician Advisor about any admissions that do not meet InterQual criteria for the level of care ordered by the admitting physician and/or questions.
Assists the Director of Case Management with utilization review processes as needed.
Provides Director of Case Management with accurate information regarding the number of observation admissions by maintaining an accurate up-to-date log of all activity per departmental policy.
Notifies Physician Advisor and Director of Case Management of all admissions that do not meet InterQual criteria as soon as possible by pager and/or e-mail.
Provides support to Case Management and the Emergency Department as needed with discharge planning throughout the continuum of care.
Assists hospital in obtaining authorization for inpatient services from third-party payers by providing them with appropriate clinical information. Documents activity in eCare.
Documents various activities according to hospital and departmental policy in the medical record and various software systems.
Interacts with Bed Control and Admission Transfer Coordinators to assist in the timely and appropriate movement of patients throughout the continuum of care.
Education:
Basic educational qualification for professional affiliation required. Bachelors degree in a Nursing or equivalent training and proven experience with applied practice in an appropriate healthcare discipline.
Education Preferred: Bachelors degree in Nursing and specialty certification preferred.
Professional Requirement: Current RN licensure in the state of Pennsylvania
