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For your reference, we have included the original job posting below.
Case Manager RN
Job Number:
23002445
Company Name:
Tri-City Medical Center
Job Location:
Oceanside, CA US
Job Category:
Healthcare & Medical
Case Manager RN
Case Manager RN Department: Case Management/Discharge Coord Category: Professional Type: Full-Time Shift: Day Description: Job Title: CM Denials Manager/Revenue Enhancement RN Duties and Responsibilities Supervise the insurance specialist This position will perform retrospective medical record chart review on recent discharges and provide clinical medical necessity reviews to ensure timely reimbursement. This position will work with business office, finance, and medical records departments to coordinate the requirements of the Centers for Medicare & Medicaid Services, such as Recovery Audit Contractors and Medicare, private insurance, governmental standards. He/she will function as a resource person to various departments involved in the review process. Utilize written criteria, standards, and norms and apply professional knowledge and clinical expertise/competence in evaluating the Medical Record and documents for appropriateness of inpatient hospitalization. Supporting the Utilization Review function of the hospital-wide committee. Working closely with the Medical Director of Utilization Review in medical staff oversight of the Utilization Review functions. Working closely with Medical Director of UR to provide on-going education and feedback to the medical staff Working closely with the Director of Case Management to provide performance indicators for the case management department. Facilitate monthly physician clinical documentation chart audits relating to appropriate level of care documentation. Appeals management is a liaison position between the hospital and the payer source, i.e. Medicare, Medi-Cal, Private Insurance Companies and CMS. The RN will manage denied cases in a timely manner and possess a sense of urgency to turn around cases based on the rules and guidelines by each payer. She will seek guidance of the Medical Director of Utilization Management for medical necessity and final approval of all correspondence written to the insurance companies. CA RN license 3+ years of experience in case management, utilization review and knowledge of Interqual criteria. Knowledge of Medicare Requirements, such as the Recovery Audit Contractors process. Problem Solving and Decision Making Review medical claims that have been denied by Medicare, private insurances, MediCal, etc. to identify medical necessity and defend the reasons why a patient met the appropriate level of care to capture loss revenue. Coordinating and gathering the data to send to denial sources in a pre-established limited time frame. This requires interpersonal skills to motivate others to collect this information. (such as business office, finance, legal, medical records and medical staff). Private insurance requirements, Medicare regulations, MediCal, etc. Internal systems such as legal, corporate compliance, medical staff bylaws, and administrative. Denial letters received by MediCal field office every Thursday; by mail to the UM department, and notification medical records for request for chart audits. Who reviews this position’s work and when? Medical Director for Utilization Review; Director of Case Management Principal Challenges: What makes the job difficult to perform? Revenue recovery from payors who do not want to give back money readily Quantitative Dimensions: Explain the position in terms of financial or quantitative dimensions. Examples include value of purchases, leases, sales, budgets managed, contracts negotiated, operating or expense budgets, authorization limits. Indicate whether the responsibility is direct or indirect. Revenue capture of denials from payors and education for proactive prevention of denials. 7. External and Internal Contacts a. External: Please indicate those key individuals by function and level, or by title and by organization, external to the Medical Center with which the position has regular contact. List the contact, such as physicians, financial institutions, customers, vendors, other businesses, etc. State the purpose of the contact and its frequency (daily, weekly, etc.). In addition, list professional and community organizations in which the position is a member (if participation is part of the job) and the capacity in which the position serves. Position Title Purpose Frequency Medi-Cal State Office Tracking/follow up Insurance companies Tracking/Follow up Legal services Cases going to court Purpose Frequency Director of Medical Records Cases requested from RAC When cases are requested TBA Patient Accounting Cases denied by Medi-Cal daily Legal Officer Cases going to court monthly UR Director Review of case and signatures to sign off and for follow up for physician education. Bi weekely Billing Find out what cases are still on hold or have been paid. Follow up with hold lists Weekly Case Mgt. Inform Case Mgt leads of cases that have been denied for f/u for education. Daily Requirements:
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