RN Care Manager, Acute Sr

Location: ORMC
At Orlando Health, we are ordinary people with extraordinary individuality, working together to bring help, healing and hope to those we serve. By daily embodying our over 100-year legacy, we reinforce our reputation as a trusted and respected healthcare organization that delivers professional and compassionate care to our patients, families and communities. Through our award-winning hospitals and ERs, specialty institutes, urgent care centers, primary care practices and outpatient facilities, our 27,000+ team members serve communities that span Florida’s east to west coasts and beyond.

Orlando Health - Benefits & Perks
All Inclusive Benefits (start day one)

• Student loan repayment, tuition reimbursement, FREE college education programs, retirement savings, paid paternity leave, fertility benefits, back up elder and childcare, pet insurance, PTO/Holidays, and more for full time and part time employees.

Responsible for ensuring an efficient, cost-effective care management process by determining the patient's medical necessity and financial liability through the coordination of insurance reviews and issuance of authorization numbers through submission of required clinical information.

Guides the care managers in the performance of medical record reviews for medical necessity of admission and the placement of the patient in appropriate bed status.

Works directly with the Care Management department, the Business Office, Patient Access, and along with the Hospital’s Revenue Cycle to ensure quality and efficiency of certain elements of claims processing, denial prevention, and denial management.

Retrieves designated reports from Allscripts Care Management and other systems in an effort to identify, organize, prioritize, and validate the requests for pre-authorizations and/or authorizations have been obtained or that appropriate, timely follow-up has been completed.

Responds to internal and external inquires in person, through telephone calls, or electronically, routing calls to appropriate individuals.

Retrieves and disseminates face sheets, consultation requests, clinical, and other information, as deemed necessary, to appropriate individual(s) in a timely manner.

Submits/faxes required/ requested clinical information to insurance company for authorization of patient hospitalization.

Coordinates insurance company requests and authorization numbers with the care managers and Patient Access Department.

Enters authorization numbers and appropriate payer documentation/correspondence into the Allscripts system.

Completes retrospective reviews utilizing the daily discharge list to validate that all patients had an initial medical necessity review completed and the outcome is favorable for reimbursement of the designated bed status. If an initial admission medical necessity was not completed, the Care Manager, Senior will assign the review to be completed by a unit Care Manager or will complete the review.

Note:

These retrospective reviews are time sensitive, due to the coding and billing guidelines and need to be completed within 3 days of the patient’s discharge. Any discrepancy needs to reconcile immediately and/or notification of the appropriate HIM or Business Office Staff to “pend” the account.

Completes retrospective medical necessity review for all readmitted patients within 30 days to identify if there is any quality of care and/or premature discharge. If a quality-of-care issue is identified and the patient’s readmission may be directly related to a failure of the treatment or discharge, discuss findings with the Physician Advisor and coordinate the processing and billing of these two admissions as one DRG.

If no quality of care or…