What You'll Be Doing
Responsibilities Include but are not limited to:
- Conducts utilization review using MCG criteria
- Promotes appropriate utilization of resources
- Participates in and supports Case Management Department initiatives
- Determines that an already-admitted patient does not meet inpatient criteria (Medicare: Code 44, OBSV)
- Escalates level of care concerns to Case Management Director and /or Physician Advisor
- Coordinates with the Patient Access team to obtain and monitor timely notices of admission for clinical review
By first business day following admission:
- Reviews admissions for appropriateness. Concurrent and retrospective admission reviews are done in accordance with MCG criteria regardless of insurance coverage or patient’s ability to pay.
- Provides Initial Clinical Review to Commercial insurance companies as indicated.
- Contacts Physician Advisor when review criteria is not met.
During patient hospitalization:
- Monitors patient’s electronic medical record to determine continued stay appropriateness.
- Completes continued stay review in AllScripts at least every third business day.
- Contacts Physician Advisor when criteria is not met.
- Identifies factors delaying discharge and facilitates correction.
- The Case Management documentation in the EMR will be the basis for peer review and patient care evaluation studies.
Each entry must be properly identified as a case management note. Every entry in the EMR must be e-signed at the time of documentation. Progress notes should show clear connections and be specific. Abbreviations should be avoided and conform to hospital policy.
What We're Looking For
Education: Bachelor’s degree in social work related field.
Experience: 2 + years related experience.
Skills: Excellent interpersonal and communication skills.
