Medical Claims Review Manager jobs in Binghamton, NY

MAIN FUNCTION:

The Utilization Review (UR) Case Manager coordinates, negotiates, procures services resources for and manages the care of complex patients to facilitate achievement of quality and cost, patient outcomes. The UR Case Manager works collaboratively with interdisciplinary staff internal and external to the organization. The UR Case Manager participates in quality improvement and evaluation processes related to the management of patient care. The UR Case Manager will review all patients for utilization management and appropriate discharge planning.

DUTIES AND RESPONSIBILITIES:

1. Determines medical necessity and appropriateness of admission and stay in accordance with Interqual screening. **

2. Prepares Medicare/NonMedicare hospital notices of non-coverage (HINN) when patient's level of care is no longer covered according to the guidelines. **

3. Identifies the appropriate patients for ED Case Management services. **

4. Maintains a working knowledge of the requirements of 3 rd party payers most frequently involved with their caseload population. **

5. Maintains a working knowledge of the resources available in the community and arrange services when possible to reduce unnecessary admissions. **

6. Communicates, collaborates, coordinates and negotiates with physicians, other members of the team, the patients payers and administrators to assess the needs and provide a plan of care for their ED caseload population. **

7. Assesses the patients within the ED caseload to identify needs, issues, resources and care goals. **

8. While housed in the ED with the patient/family, other members of the health care team, the payer, and available resources, formulates a plan to address assessed needs and issues, implements/initiates the plan, evaluates the effectiveness of the plan in meeting established care goals and revises the plan as needed to reflect the changing needs, issues and goal. **

9. Evaluates the effects of UR Case Management in regards to readmissions and high ED utilization on target populations. **

10. Educates, health team colleagues about UR Case Management, including the role and the unique needs of case managed patient population. **

11. As a member of the Utilization Review Case Management practice: **

• Seeks and provides peer consultation about cases presenting problems and/or experiencing significant deviation from the plan of care.
• Arranges for and participates in coverage during long, short, and unexpected absence of self and other utilization review case managers.
• The UR Case Manager has knowledge of LOS, resource utilization, outliers, readmissions, denials, delay days and satisfaction of the case managed population.
• Attends UR CM staff meetings.
• Maintains a close working relationship with physicians managing the care of their ED population.

12. Coordinates patient discharge and transfers based on the patients need and available Resources from the ED. **

13. Coordinates services, i.e. home help, DME etc, based on patient need and resources available from the ED.**

14. Acts as a resource to the team regarding insurance benefits, managed care processes, and utilization issues in the ED. **

15. Is responsible for attending all annual mandatory educational programs as required by position. **

16. Employee understands and demonstrates the importance of satisfying the needs of the customer/patient by interacting with him/her in a friendly and caring way, being attentive to the customer’s needs, both psychologically and physically, and by taking the initiative to maintain communication with the customer in order to provide a secure and pleasant experience with the Medical Center. **

17. It is understood that this lists typical duties for the classification and is not to be considered inclusive of all duties, which may be assigned.

MEETINGS:

UR Case management staff meeting. Case management staff development meetings.

EDUCATION:

Graduate of an approved registered nursing program with a current license as a Registered Nurse. BSN highly preferred.

EXPERIENCE:

Three years clinical nursing in acute care hospital setting or two years utilization management in an acute care hospital setting. Case Management/Utilization Review management experience preferred but not required.

CARDIOPULMONARY RESUSCITATION (CPR) REQUIREMENTS:

BLS required.

PHYSICAL DEMANDS:

Light physical effort. Routine office job.

EXPOSURE CATEGORY:

Category I. Tasks that involve exposure to blood, body fluids, or tissues.

** A.D.A. Essential Functions