Posted in General Business 30+ days ago.
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Location: Glendale, California
Basic Job Purpose:
This position carries consultative, educational and clinical responsibilities; the overall objective is to ensure the implementation of case management policies.
Representative Functions and Duties:
1.Responsible for admissions, concurrent and/or retrospective reviews of all patients in accordance with the criteria and the policies and procedures approved by the Performance Improvement Committee, and consistent with Federal and State guidelines, PRO regulations, JCAHO standards and contractual agreements with insurers or outside review agencies.
2.Serves as a liaison to: a)Health Information Management (HIM) b)Business Office c)Patient and Family Services d)Nursing/Ancillary Services e)California Medical Review, Inc. f)Insurance Payors/Review Agencies g)Admitting Department h)Physicians i)Performance Improvement Committee (PIC) j)Risk Management Department k)Medi-Cal l)Infection Control m)Pharmacy Department
3.Promotes appropriate utilization of facilities and services.
4.Collects, aggregates, displays and conducts first level analysis of data obtained from monitoring and evaluating the quality and utilization of patient care. Collaborates with Quality Management regarding findings.
5.Interacts with the medical and support staff and/or hospital committees to facilitate the recognition, research, isolation and resolution of questions or potential problems.
6.Utilizes data gathered by collaborating with the appropriate health care personnel to perform CMRI (California Medical Review, Inc.) reporting, mortality screening, reports to risk manager, and reports to PIC.
7.Ensures appropriate reimbursement and authorizations from third party payors and their representatives for acute level patients. Educates the medical staff and other health care providers regarding proper documentation of rendered services.
8.Assists Performance Improvement Committee and medical staff committees in identifying and resolving existing utilization and/or quality problems.
9.Supports the CQI process.
10.Participates with HIM in the DRG collaboration process.
11.Performs concurrent open medical record review.
12.Audit charts to meet Medicare requirements for skilled care.
13.Responsible for processing Medi-Cal TARS (Treatment Authorization Request) and obtaining physician signature in a timely manner.
14.Collaborates with discharge coordinator regarding patient cases not meeting intensity of services/severity of illness criteria.
15.Initiates the appeal process upon notification of denial by business office.
16.Demonstrates knowledge of pediatric, adolescent, adult and geriatric variations in treatment/procedure as evidenced by annual age specific competency assessment/evaluation.
17.All other duties as assigned.
REQ20075510 Posted Date: 06/14/2019