Behavioral Health RN Care Coordinator

Overview

You Matter Here!

Heywood Healthcare values our employees! We offer competitive wages, great benefits and generous earned time off. Come work where you will matter!

Hours:
Per Diem, day shift, no weekends/holidays

$

Disclaimer:

We are committed to equitable and transparent compensation practices. The salary range for this position reflects our good-faith estimate of base pay at the time of posting. Final compensation will be determined based on a variety of factors, including relevant experience, skills, qualifications, and internal equity. We regularly review our compensation structures to ensure fairness and consistency across our organization.

Essential Functions

• Utilization Management - Utilization Review and Care Transitions & Coordination
  • Providing clinical information to payers, monitoring length of stay, seeking necessary care authorizations and appealing denials as indicated within a timely fashion.
  • Follows-up on lack of documentation for medical necessity, supporting documentation with discipline identified.
  • Track and trend opportunities for improvement resulting in late Insurance Reviews, longer lengths of stay
  • Completes utilization reviews daily and/or as required by insurer, (concurrent and retro) for psychiatric appropriateness according to Hospital's approved criteria timely and efficiently.
  • Demonstrates clinical expertise specific to the issuance of ABN/HINN notice to patients and/or legal significant other and care progression. Responsible for insurance interactions related to Medicare Important Message appeal process. Keeping physician and team informed of status change and documenting status.
  • In collaboration with the BH Clinical Team provides education and information to patient, family and care providers as it pertains to continuing care, care management, LOS, re-hospitalization and assure understanding of disease management.
• Multidisciplinary Team Rounds -
  • Participates in discharge planning teams daily.
  • Works collaboratively with multidisciplinary team to determine each patient's needs concurrently including post-acute care when needed; addresses LOS issues, appropriate leveling of patient status; addresses, potential needs, resources, referrals for other disciplines etc.
• Quality & Statistical Data -
  • Reviews medical record for abnormal findings,complications, delays and deviations from expected clinical outcomes reports such to Provider and/or Director to maintain an efficient, cost effective episode of care for each patient and documents intervention provided.
  • Maintains current working knowledge regarding regulatory requirements and insurance review procedures, forms, and portal updates.
  • Utilizes knowledge to redesign systems for improving performance.
  • Continuously prioritizes projects, activities, and tasks to ensure deadlines and customer needs are met.
  • Assists with preparation of reports/statistics as it pertains to staff specific workflow.
  • Reviews pre-admission screen forms for accuracy. Note any pre-authorized dates of service and insurance specific communication related to concurrent review/discharge notification.
  • Responsible for correcting issues with pre-auth to ensure reimbursement – including obtaining auth for patients who are admitted without proper auth in place.
  • Conduct daily comprehensive utilization reviews for inpatient psychiatric and substance use disorders to ensure compliance with medically necessary criteria.
  • Request administratively necessary days when a patient no longer meets criteria for inpatient level of care. Determine state involvement as reimbursement for DMH active clients differs from the standard Medicaid rate.
  • Participate in 72 hour meeting with patient/HCP/Family/Guardian,Social Worker, and Unit Leader to facilitate education regarding anticipated LOS and advance discharge planning inititation/expectations.
  • Attend collaborative meetings with insurers to review statistical trends, discuss complex cases, and review quality data reports
• Denials/Appeal Process -
  • Completes assessment of denial within 1 week providing supporting documentation with outcome of review; documents intervention in the UR EMR section.
  • Coordinates Medical Director and Peer to Peer reviews in accordance with insurance regulations.
  • Prepare written appeal letters, termination letters, discharge notices, MOON and IMs when appropriate as per regulatory standards and department policies.
  • Report any variances, trends to director. Submits denials/appeals when completed.
  • Collaborate with Director of…