Medical Mgmt Clinical Coord-CMO; JR

Introduction

To heal, to teach, to discover and to advance the health of the communities we serve.

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Working with IPA other members of the interdisciplinary care team, and CMO Medical Directors and in accordance with regulatory and benefit coverage parameters, helps determine and coordinate comprehensive care plans 'appropriate to the health care needs of IPA members, including but not limited to, inpatient hospitalization, outpatient services, professional services, home care, durable medical equipment and other ancillary services. Evening and weekend hours may be required.

• Perform ongoing review in assigned cases where members are receiving extended services to ensure that members are receiving the services authorized and to determine the continued appropriateness of the services.
  • Conducts reviews in all cases where members are receiving extended services on a regular basis but at intervals of no greater than two weeks. Documents involvement of the member and/or significant other(s), Primary Care Physician and/or specialist and all other involved health care providers are included in determining the need for ongoing care. Modifies the plan of ongoing care as necessary in consultation with the member, significant other, Primary Care Physician and/or specialist and other involved health care providers.
    
    Reviews cases with CMO Medical Director or Associate Medical Director, in accordance with departmental policies and procedures.

• Reviews and evaluates authorization requests for inpatient, outpatient, specialty and out-of-network care and all other services requiring authorization within time frames and in accordance with criteria/guidelines specified by departmental policies and procedures.
  • Completes 100% of assigned authorization reviews within the time frames required by regulation and specified by departmental policy and procedure or appropriately documents variances in any case not meeting time frames.
  • Applies appropriate criteria/guidelines in the review of authorization requests.
  • Interprets criteria/guidelines accurately.
  • Acts as a resource to UM Analysts, adjudicating authorizations as per departmental policy and procedure.
• Identifies cases requiring case management and refers them to case management staff in accordance with departmental guidelines.
  • Refers 100% of cases falling into those categories designated by departmental policy to appropriate case manager for evaluation.
• Using guidelines/criteria specified in departmental policies and procedures, identifies cases where services requested may not be medically necessary, requests pertinent clinical information and forwards available information to the Medical Director or Associate Medical Director for review.
  • Reviews 100% of requests for service as well as ongoing care in accordance with appropriate criteria.
  • Documents efforts to obtain additional clinical information in accordance with departmental policy and procedure in 100% of cases where this is required.
  • Forwards identified cases involving issues of medical necessity to the Medical Director or Associate Medical Director for review.
  • Monitors Response time frames and or escalates to management all variances.
• Facilitates the discharge planning process for hospitalized members.
  • Documents anticipated discharge plan at the time of the initial inpatient review. Evaluates post discharge needs involving interdisciplinary professionals through daily rounds, team conferences and written communication.
  • Provides information as re: benefit coverage as needed, as well as available community services when appropriate.
  • Ensures that the discharge plan is communicated to all disciplines in an expeditious manner and identifies and documents barriers to a timely discharge.
  • Documents all variances resulting in potentially avoidable days in the UM system.
  • Provides timely…