Regional Claims Manager jobs in Bellingham, WA

The information described in this job description has been designed to indicate the general nature of the work performed. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this job.

Other information:

Job Summary
The position involves coordination of services to improve and maintain quality patient care and to ensure appropriate utilization of healthcare resources. Serves as a liaison between the hospital, providers, and external payers on issues related to intensity of service and severity of illness for patients. Ensures the timely and seamless transition of patients through medically appropriate levels of care. Conducts patient status and medical necessity reviews at the time of hospital admission and also concurrently throughout the stay. Reviews are documented in designated systems according to standard. In collaboration with physicians, promptly addresses documentation discrepancies. .

Essential Functions
Conducts and documents medical necessity reviews that demonstrate delivery of reasonable, necessary, and appropriate (according to evidence-based clinical standards of practice) patient care. Collaborates with contracted resources for external medical necessity reviews and audits. Documents Changes of Status (COS) and completes supporting paperwork. Performs readmission assessments utilizing indicated focus study. Assists with insurance requests for clinical reviews and continued stay authorizations. Provides physician education on medical necessity criteria. Participates in medical necessity audits. Assists with non-Medicare appeals research and preparation of written correspondence. Facilitates Medicare discharge appeal process through contracted Quality Improvement Organization (QIO). Participates in family care conferences as needed. Captures potentially avoidable days (PADs) and documents in designated system. Collaborates with physicians, nursing, social work, and other disciplines, departments, payers, and agencies to eliminate barriers to an efficient transition through the care continuum. Collaborates with discharge planning team, and assists in the facilitation of discharges as needed. Supports Population Health initiatives through patient outreach activities as assigned. Adheres to regulatory agency guidelines/requirements governing patient notification (ie Important Message from Medicare, Medicare Outpatient Observation Notice, Hospital-Issued Notice of Non-coverage). Complies with all SRH Policies and Procedures. Performs other duties as assigned by Manager or Designee.

Education
BSN required unless a Certified Case Manager (CCM), or 2 years equivalent experience.

Experience/Training
Minimum three (3) years clinical practice experience required. Previous utilization review experience strongly desired. Experience using medical necessity screening criteria preferred.

License/Certifications
Current Washington State RN License required. Certified Case Manager (CCM) or Certified Professional in Healthcare Management (CPHM) preferred.

Other Skills
Excellent communication, organizational and interpersonal skills. Ability to work independently and manage time and decisions. Proficiency with standard software applications including spreadsheets and word processing. Knowledge of healthcare law and regulations related to acute care and the immediate post-acute continuum helpful.

Physical Demands and Work Environment
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk and hear. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to focus. This position involves repetitive tasks such as typing, sitting, answering phones, and interacting with computers and computer systems, and also requires standing and walking for extended periods.Skagit Regional Health offers a comprehensive benefit package including medical, dental, vision, 457b/401a (retirement), long term disability, and paid time off to all employees holding an FTE of 20 or more hours per week. Eligible employees also receive sick time pay.