Want to know if you’re a fit? Upload your resume and let our AI show you.
Skills
Case Managementunmatched
Clinical Informationunmatched
Clinical Study Publicationsunmatched
Documentationunmatched
Documentation Reviewunmatched
Hospitalunmatched
Managed Careunmatched
Medicaidunmatched
Medical Recordsunmatched
Medicareunmatched
Medication Administrationunmatched
Outpatient Careunmatched
Quality of Careunmatched
Registered Nurse (RN)unmatched
Riskunmatched
Time Managementunmatched
Utilization Managementunmatched
Description
• Identify appropriate medical information necessary to certify and/or refer cases on admission and on continued stay reviews.
The review of the medical record includes all pertinent information required by insurance payers including the reason for admission, current symptoms, abnormal lab values, abnormal diagnostics, outpatient condition prior to an admission and response or lack of response to such treatment. Review medication administration record to identify antibiotics administered, dose and frequency, respiratory treatments, medical/surgical and social history. Documentation if discharged from a hospital within 30 days, as well as any pertinent clinical information.
Performs assigned admission reviews within established time frame in accordance with payer requirements as well as daily reviews for Medicare, Medicaid and managed care companies per their requirements.
Ensures timely provision of clinical review information to payer as evidenced by no denials for lack of clinical information. Collaborates with patient registration /resource services for issues related to insurance coverage (i.e., correct insurance is not in patient record.
Whenever possible, manages requests for concurrent reconsiderations as evidenced by the "overturn" of the initial denial decision.
Initiates collaboration with the Medical Staff or Clinical Documentation Specialists by identifying additional clinical information required for obtaining payer determination for approval of the admission.
Identifies hospital stays at risk for admission downgrades or denials and involves the Physician Advisor in a timely fashion when assistance is needed.
Refers cases to the Physician Advisor when a change in level of care or termination of benefits seems applicable based upon criteria for Medicare/Medicaid patients (i.e., certification of acute days versus custodial or SNF).
Utilizes case management software including utilization criteria guidelines, to capture essential admission clinical review documentation.