1. Provides timely and thorough clinical information to insurance companies and other intermediaries to secure payer authorizations and avoid denials or reduction in level of care.
2. Performs daily surveillance of observation cases and works with PA discussing any barriers to progression of care or discharge.
3. Intervenes proactively to avoid denials or delays in authorization.
4. Actively communicates information to other CM team members and interdisciplinary teams regarding progress or payer issues related to continued hospitalization and post-acute service associated with the patients discharge plan.
5. Refers cases and issues to Physician Advisors or Designees in compliance with department procedures with timely follow up as indicated
6. Assists in identification and collection of avoidable days
7. Coordinates with the CM RN and/or CMA to identify and complete the process for CMS required patient notices.
8. Completes and documents utilization reviews, physician advisor referrals and other communications related to assigned cases in accordance with department policy and procedure.
9. Complies with the Condition of Code 44 process, CMS required patient notices and other regulatory requirements within the utilization management process.
10. Maintains proficiency in the application of organization selected clinical review criteria sets evidenced through IRR testing