To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
The Clinical Denial Management & Utilization Coordinator Serves As The Hospital Expert In The Utilization Management Process As They Relate To Outpatient In A Bed And Hospital Services, As Well As Transfers From Both Internal And External Sites. Review All Denials For Medical Necessity And Appealabilty Utilizing Inter Qual Criteria. Circulate Through Patient Care Areas And Ancillary Areas To Expedite Appropriate Patient Placement Partnering With Ancillary Supervisors To Expedite Room Turnover And Patient Transportation. Collaborates With Other Members Of The Health Care Team To Ensure Continuity Of Care And Best Possible Patient Outcome. Provides Education, Formal And Informal With Physicians, Staff And Patients Regarding Level Of Care And To Facilitate Denial Management Stragedies.
- 1. Serves As An Expert Resource, And Consultant Related To The Control Of Utilization Of Outpatient In A Bed And Inpatient Hospital Services That Include Certification Of Medical Necessity Based On Plan Of Care And Utilization Review.
- 2. Serves As A Clinical Liaison For Physicians, The Admitting Department, Nursing Units, Outpatient Services, Environmental Services And The Emergency Department To Ensure Appropriate Level Of Care And Patient Bed Assignments, Providing Direction As Needed.
- 3. Uses Strong Clinical Knowledge Base To Review Developmental Appropriate Patient Assessment, Plan Of Care, And The Intervention For Patient Outcome. Applies Interqual Guidelines Criteria To Evaluate Denied Claims For Appeal Ability.
- 4. Reviews All Level Of Care For Appropriateness And Works Closely With Providers And The Revenue Cycle To Assure Reimbursement Of Services.
- 5. Maintains Knowledge About All Units As To The Type Of Patients Each Unit Can Accept, Including The Type Of Equipment And Medications That Can Be Given.
- 6. Maintains Clinical Competency And Current Knowledge Of Regulatory And Payer Requirements Required To Perform Job Responsibilities.
- 7. Oversees The Hospital Notice Of Non-Coverage Process Which Includes Responsibility For Notification Of All Appropriate Parties When Letters Are Issued.
- 8. Participates In The Orientation And Education Of The Case Management Department Related To Utilization Management Processes.
- 9. Maintains Proficiency In Each Aspect Of Utilization Review And Management Including Managed Care Contracts.
- 10. Participates In Physician And Physician Office Staff Education Related To Acute Care Utilization.
- 11. Communicates And Collaborates Effectively With A Variety Of Persons, Including The Patient, Public, Coworkers, Guests, Payers, Outside Agencies, And Medical Staff.
- 12. Maintains And Promotes Customer Satisfaction.
- 13. Organizes And Performs Work Responsibilities Effectively And Efficiently.
- 14. Communicates With The Emergency Department Frequently To Prevent Delay Of Admissions/Placements And To Put Procedures In Place That May Prevent A Backlog.
- 15. Screening Elective Amu/Asu Procedures (Inpatient/Outpatient) For Appropriate Level Of Care (Meditech/Order Match) And Existence Of Pre-Op Order For Inpatient Cases
- 16. Demonstrates A Commitment To Process Improvement Through Focusing On Quality And Service.
Registered Nurse With Current Ct License. Bachelors Degree Required. Masters Degree Preferred.
A Minimum Of Two (2) Years Of Recent Experience In Case Management, Utilization Management, Or Managed Care Required.
Current Ct Licensure
Requires Excellent Observation Skills, Analytical Thinking, And Problem Solving And Good Verbal And Written Skills. Basic Computer Skills.