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.
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
Diploma or degree in Nursing required. BSN preferred. Current RN license to practice in the State of Louisiana required. Minimum of 3 years experience as a RN in a clinical or similar setting also required. Experience and knowledge of 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.
Peoples Health, Inc. - 2 years ago
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