UCR/Case Management

UCR/Case Management

Almoosa Specialist Hospital
2-5 years
Not Specified

Job Description


Duties and Responsibilities:
-Performs perspective review to determine the following
-If insurance coverageand benefits are verified.
-If managed care program requirements are met.5.1.3Care is rendered at the most appropriate level of care.
-Selection of provider is appropriate and within the preferred network if possible.
-Initial length of stay (LOS) is determined if the patient is inpatient
-Determines if appropriate service codes have been selected
-Determines if all investigations, tests, procedures and visits have been captured during the care episode.
-Assessment needs /discharge planning is initiated.
-Performs concurrent review of care episodes while the patient is in the Health Facility to determine the following:
- Accurate patient information is captured in a timely fashion.
- Care continues to be provided at an appropriate level of care and with the appropriateutilization of resources.
-Care is coordinated
-Insurance coverage benefits still match the patient's requirements.
-Financial criteria of discharge screening are met.
-Performs retrospective review of case files to audit care episodes for claims preparation and/or justification and analysis purposes.
-Attend daily meetings to enhance communication between Multidisciplinary purposes.
-Obtain medical justification reports and other related documents required to enhance the approval process.
-Collaborate with the multidisciplinary team in the identification of financial issues related to the treatment plan and the solving of these issues.
-Responsible for the disseminating of any financial data to the multidisciplinary team within the service that they are allocated to.
-Participate in continuous quality improvement through interdisciplinary team measurement, assessment and improvement of patient care delivery processes and services resulting in enhanced quality and appropriate resource management.
-Collaborate with all members of the utilization and Clinical Review Department to enhance all aspects of the resource utilization management program.
-Provide personalized coordinated care, support and treatment for patients and families.
-Treat people with dignity, compassion, and respect.
-Involve patients,familiesand caregivers by providing them with education and resources for offering optimal support to promote recovery.
-Ensures confidentiality of all patient records and derived data.
-Attends mandatory ASH orientation programs and participate in the Departmental orientation and in-service training programs
-Performs any other tasks and duties appropriate to his / her.
-realm of knowledge, skills and experience, as required by the Department Head
Nursing Degree or Diploma from a recognized School of Nursing or College Degree in a related healthcare field
-Minimum of Three (3) years experience in a large hospital or health management organization (HMO) with demonstrated clinical and administrative skills.
-Familiarity with application of insurance industry standards, preferably in a managed care setting.Minimum of 2 years practical experience in Direct care service.
-Understanding of coding mythologies such as ICD-10 DRG and CPT.
-Well experienced with hospital information systems and personal computer software programs.
-Extensive knowledge of surgical procedures.
-Fluent in written and spoken English

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