Case Manager; H) in Hialeah, Florida

Core Utilization Case Manager - SCT

Reviews the medical records of all outpatients, observation, and inpatient admissions to determine medical necessity for admission and continued stay, using pre-established criteria on a daily basis. Continued review of all patients using criteria and determines need for continued hospitalization based upon third party payer/insurance guidelines. Provides clinical data/information to contracted third-party payers while patient is hospitalized to ensure continued reimbursement and to avoid reimbursement delays within 24 hours of request.

Interacts, communicates, and intervenes with multidisciplinary healthcare team in a purposeful, goal-directed fashion. Works proactively to maximize the effectiveness of resource utilization. Anticipates, initiates, and facilitates problem resolution around issues of resource use and continued hospitalization and discharge planning. Participates in interdisciplinary patient care rounds to review care plan and treatment goals, facilitates cost effective utilization of patient services, and ensures that appropriate referrals are initiated.

Establishes a means of communicating and collaborating with physicians, other team members, the patient's payers, and administrators. Explores strategies to reduce length of stay and resource consumption within the care-managed patient populations, implements them, and documents the results. Communicates to appropriate members of healthcare team the patients at risk of losing insurance coverage via termination of benefits and facilitates discharge plan.

Maintains a proactive role to ensure appropriate documentation concurrently to minimize inefficient resource utilization and prevent loss of reimbursement. Reviews physician documentation and, when needed, follows procedures to seek clarification of documentation relative to diagnosis. Maintains current knowledge of case management, utilization management, and discharge planning, as specified by federal, state, and private insurance guidelines. Optimizes use of time by efficiently using resources to identify barriers and balance priorities.

Efficiently utilizes tools, resources, techniques, and/or systems to organize tasks. Balance multiple priorities simultaneously, ensuring the timely and accurate completion of each task while maintaining quality standards. Develops criteria to financially screen potential BMT patients, evaluate and determine if a patient is eligible for financial clearance for transplant, and maintain an electronic log of eligible and non-eligible patients. The individual will be expected to access, analyze, and guide all potential adult stem cell transplant candidates through the transplant financial process.

Ensures all staff members adhere to all established policies and procedures related to the business operations and continuously monitors compliance. Responsible for correcting actions that are out of compliance. Schedules and registers patients and donors as per established policies and procedures in UChart as required. Coordinates clinical appointments with nurses, physicians, physical therapists, and technician in order to maximize patient access to inpatient and outpatient BMT program.

Obtains pre-certification, authorizations, from medical review insurance companies and/or designated payors and initiates Letters of Medical Necessity when requested. Obtains required patient/guarantor signatures where applicable and counsels patients and/or surrogates to explain their particular coverage benefits and financial responsibilities available through their specific healthcare plans throughout the transplant process. Determines patient's eligibility for financial clearance for Stem Cell Transplant based on criteria utilizing patient's financial information provided.

Ensures accurate billing of services is rendered and ensures collections of all co-payments, co-insurance amounts, deductibles, and non-covered amounts for both Hospital & Professional prior to procedure by establishing system to track compliance. Addresses all financial inquiries, regarding patient accounts, potential new referrals for hospital services, and coordination of same with departments involved with case or pertinent outside healthcare entity.

Consults with Transplant Coordinators, and the Adult Stem Cell Transplant Attending Physicians regarding the financial status of the transplant patient referral for financial approval or denial for the transplant program.