Job Description

Organization: ABSMC-Alta Bates Herrick Campus

Position Overview: Accumulates, interprets, and documents timely information to justify acute hospital admission, need for continued stay, and proper utilization of physician, nursing, and ancillary services. Responsible for concurrent review on specific patients. Develops, coordinates and monitors systems for the appeal/denial process, tracks and trends data, and coordinates utilization management activities for the assigned area. Collaborates with hospital administration, medical staff, patient registration and representatives of review organizations and others to ensure effective utilization of services and appropriate service reimbursement. Monitors and acts as a liaison between external payers, internal business office, admissions staff, and clerical unit staff to assure that quality care is delivered at the appropriate level of service and that documentation of care meets appropriate standards. Interfaces with hospital administration and unit medical doctors and provides data related to the current management of resources. Adheres to all local/state/federal regulations, codes, policies and procedures to ensure privacy and safety while delivering optimal patient care.

Job Description:

These Principal Accountabilities, Requirements and Qualifications are not exhaustive, but are merely the most descriptive of the current job. Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job change (for example, emergencies, staff changes, workload, or technical development).

JOB ACCOUNTABILITIES:

CASE MANAGEMENT:

• Review all identified cases for potential barriers to discharge.
• Focus on length of stay outliers and elimination of barriers for patients to be moved to lowest level of appropriate care.
• Maintain contact with attending psychiatrists and case managers to help as a member of the team to remove barriers to appropriate level of care.
• Provide management and technical expertise in identifying chart documentation problems which impact reimbursement.
• Collaborate with case managers, clinical nursing staff and others to ensure appropriate utilization and quality care through utilization review, tracking and evaluation and objectively compare criteria with written documentation. Track and trend timely appeal/denial data, following up with appropriate staff/departments.
• Conduct retrospective and current chart review to validate documentation when requested by review agencies.
• Create, modify, and update data collection parameters, methods of collection, reporting content and format. May perform trending and create summary reports.
• Review medical records documentation in response to denials or authorizations for level of care issues and length of stay as received from managed care or third party payors. Appeal adverse review decisions, notify appropriate staff when authorization/reimbursement cannot be certified. Provide information to case managers, clinical nursing staff and other departments regarding documentation required for utilization review activities and processes. Collaborate with medical, nursing and other professional personnel to help interpret utilization review program changes and implement revisions to operational procedures.
• Collaborate with case managers, clinical management, clinical nursing staff and hospital staff to ensure quality issues are documented and reported, including addressing physician performance issues through chart documentation identification, improvement and education.
• Communicate with patients in a clear and professional manner to alleviate confusion and expedite processes.
• Ensure that routine and priority tasks are completed within established departmental time frames.

CLERICAL:

• Perform general clerical tasks.
• Prepare and complete accurate, job-related documentation, including collecting, updating, and maintaining patient medical and insurance information.

SAFETY:

• Maintain a clean, neat, and safe working environment, including organizing files and keeping desks free of loose papers and clutter.

COMPLIANCE:

• Perform job responsibilities in compliance with department standards, policies, and procedures, as well as local, state and federal regulatory agencies to deliver the highest level of service.
• Maintain strictest confidence of all patients protected health information (PHI) and protects all PHI from accidental, intentional, or inappropriate disclosure.

EDUCATION:

Equivalent experience will be accepted in lieu of the required degree or diploma. Bachelor's: Business Administration or related field.

DEPARTMENT REQUIRED EDUCATION:

Equivalent experience will be accepted in lieu of the required degree or diploma. Department, Behavioral Health: Master’s in Social Work or related field.

SKILLS AND KNOWLEDGE:

• Working knowledge of medical terminology, including general knowledge of illnesses, current treatments and their physical and psychosocial sequelae.
• Knowledge of alternate levels of care including criteria required for payment and applications processes.
• Ability to interpret a variety of data and instructions, furnished in written, oral, diagram, or schedule form.
• Possess written and verbal communications skills to communicate with fellow team members, supervisors, patients, and other hospital personnel.
• Well-developed time management and organizational skills, including the ability to prioritize assignments and work within standardized policies and procedures to achieve objectives and meet deadlines.
• Demonstrated knowledge of computer applications, such as Crystal Report writing, Midas Plus, Excel, Sunrise, MS Word, PCIS, and InterQual.
• Work independently, as well as be part of the team, including accomplishing multiple tasks in an environment with interruptions.
• Identify, evaluate and resolve standard problems by selecting appropriate solutions from established options.
• Ensure the privacy of each patient’s protected health information (PHI).
• Build collaborative relationships with peers and other staff members to achieve departmental and corporate objectives.

PHYSICAL ACTIVITIES AND REQUIREMENTS:

See required physical demands, mental components, visual activities & working conditions at the following link: Job Requirements

Job Shift: Days

Schedule: Per Diem/Casual

Shift Hours: 8

Days of the Week: Variable

Weekend Requirements: As Needed

Benefits: No

Unions: No

Position Status: Non-Exempt

Weekly Hours: 0

Employee Status: Per Diem/Casual

Number of Openings: 1

Sutter Health is an equal opportunity employer. EOE/M/F/Disability/Veterans.

Pay Range: $46.29 to $69.44 / hour

The salary range for this role may vary above or below the posted range as determined by location. This range has not been adjusted for any specific geographic differential applicable by area where the position may be filled. Compensation takes into account several factors including but not limited to a candidate’s experience, education, skills, licensure and certifications, department equity, training and organizational needs. Base pay is just one piece of the total rewards program offered by Sutter Health. Eligible roles also qualify for a comprehensive benefits package.

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