Telephonic Review RN (Baton Rouge)
Peoples Health, Inc. - Baton Rouge, LA

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Will support accurate medical management of members through the authorization of in-patient admission, concurrent review, level of care transfers and discharge process. Will include the member's physician/hospital authorization process for out of area facilities and in-network inpatient admission as well as the coordination of member's discharge needs of Home Health, DME, and social worker/case management referrals.

Responsibilities:
  • Responsible for reviewing authorization requests for inpatient admissions against InterQual criteria/DRG Management model
  • Responsible for inpatient concurrent reviews as needed for inpatient admissions in-network and out-of-network.
  • Coordinates, when medically appropriate, facility transfers from an out-of-network facility admission to an in-network facility.
  • Coordinates, when medically appropriately, to an appropriate level of care within the admission facility and/or transfer to an appropriate facility.
  • Coordinates the Medical Review Unit referrals when appropriate
  • Communicates with Medical Director(s) when appropriate with in-patient authorization process.
  • Coordinates discharge plans with the hospital case manager and social worker if required for hospitalized patients.
  • Assists in the resolution of claims pended in system.
  • Sends NODMAR notices to specific patients at time of discharge by mail/fax.
  • Responsible for issuing authorization numbers to the hospitals when appropriate and approved.
  • Responsible for entering authorization data into the Amisys and MACESS systems upon notification of admission, concurrent reviews and notice of discharge.
  • Responsible for being knowledgeable for individual plans/benefits administered by Peoples Health
  • Contributes to the data for monthly Utilization Management and Quality Improvement reporting.
  • Reviews census spreadsheets on a daily/weekly basis and notifies Census Coordinator of any necessary changes.
  • Participates in the orientation program of new staff members.
  • Periodic reviewing of data entry to ensure accuracy and appropriate documentation of information.
  • Participates in Medical Management Team and departmental meetings
  • Completes Case Management Form on patient identified as needing a referral to Case Management or Social Services.
  • Ability to travel to different regional offices depending on staffing issues

Qualifications:

Diploma or degree in Nursing requied. BSN preferred. Current license to practice in the State of Louisiana required. Minimum of 3 years experience in a clinical or similar setting also required. Experience and knowledge with computers also required. Experience in managed care/insurance industry a plus!Understanding of HMO and third party administration needed. Ability to effectively interact with multifaceted medical professional staff also required. Computer skills necessary.

Peoples Health, Inc. - 2 years ago - save job
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