RN Care Manager, Acute Sr.

Location: ORMC at Orlando Health

About the role

Responsible for ensuring an efficient, cost-effective care management process by determining the patient's medical necessity and financial liability through the coordination of insurance reviews and issuance of authorization numbers via submission of required clinical information.

Responsibilities

• Guides care managers in performing medical record reviews for medical necessity of admission and appropriate bed status placement.
• Works directly with the Care Management department, Business Office, Patient Access, and the Hospital’s Revenue Cycle to ensure quality and efficiency in claims processing, denial prevention, and denial management.
• Retrieves designated reports from Allscripts Care Management and other systems to identify, organize, prioritize, and validate requests for pre-authorizations and/or authorizations.
• Responds to internal and external inquiries in person, by telephone, or electronically, routing calls to appropriate individuals.
• Retrieves and disseminates face sheets, consultation requests, clinical, and other information to appropriate individuals in a timely manner.
• Submits/faxes required clinical information to insurance companies for authorization of patient hospitalization.
• Coordinates insurance company requests and authorization numbers with care managers and the Patient Access Department.
• Enters authorization numbers and appropriate payer documentation/correspondence into the Allscripts system.
• Completes retrospective reviews using the daily discharge list to validate that all patients had an initial medical necessity review completed with a favorable reimbursement outcome. If not completed, assigns the review to a unit Care Manager or completes it personally. These reviews must be completed within 3 days of discharge.
• Completes retrospective medical necessity reviews for all readmitted patients within 30 days to identify quality-of-care issues or premature discharge. Coordinates with the Physician Advisor and business office to process billing appropriately.
• Assists in appealing existing denials by communicating necessary information to payers and proactively preventing denials by collaborating with care management staff, bedside nurses, physicians, and the Physician Advisor.
• Actively assists with payer requests for Peer-to-Peer reviews.
• Demonstrates knowledge and skills necessary to provide appropriate care considering the growth, development, and social needs of pediatric, adolescent, adult, and geriatric patients.
• Enhances professional growth and development through participation in educational programs, current literature, in-service meetings, and workshops.
• Maintains reasonably regular, punctual attendance consistent with Orlando Health policies and federal, state, and local standards.
• Maintains compliance with all Orlando Health policies and procedures.
• Assists Business Office personnel in preparing documentation related to admission, denials, and appeals.
• Communicates with payers to facilitate covered-day reimbursement authorization for assigned patients.
• Discusses payer criteria and issues on a case-by-case basis with clinical staff to resolve issues and avoid denials or reimbursement penalties.
• Escalates cases to the Physician Advisor when patients do not satisfy criteria or when quality-of-care concerns are identified.
• Assists Care Managers in identifying patients with barriers to discharge or high risk of readmission, communicating findings to payers and the Care Management Team.
• Reviews payer requirements and government regulations to ensure compliant, safe healthcare.
• Assigns tasks to care management assistants and makes appropriate referrals to Social Work Care Coordinators to achieve desired treatment outcomes.
• Interprets problems and selects solutions based on past similar situations.
• Plans events expected to occur within one to four weeks or monthly.
• Regularly contacts employees to discuss moderately important issues and respond to inquiries, including external contacts and public interactions requiring cooperation, explanation, and persuasion.

Requirements

• Graduate of an approved school of nursing.
• Current license as a Registered Nurse (RN) in Florida.
• Certification as an InterQual trainer within six (6) months from date of hire.
• Five (5) years of acute clinical experience, including at least two (2) years in utilization management, chronic disease management, care management, or care coordination.
• Extensive knowledge of professional discipline and working knowledge of related fields.
• Understands information in several unrelated professional disciplines.

Benefits

• All-inclusive benefits starting on day one, including student loan repayment, tuition reimbursement, and free college education programs.
• Retirement savings plans.
• Paid paternity leave and fertility benefits.
• Backup elder and childcare, plus pet insurance.
• Paid time off (PTO) and holidays for full-time and part-time employees.

Forbes has named Orlando Health as one of America's Best-In-State Employers for 2024, and Orlando Health has been selected as one of the “Best Places to Work in Healthcare” by Modern Healthcare.