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Position Details

Department: Case Management
Category: Care Mgmt/Social Wrk/Case Mgr
Location: Phoenix
Posting #: 453280
Date Posted: 5/20/2019
Employee Type: Regular

Position Summary

This position provides comprehensive assessment, coordination, implementation and reporting of complex clinical data. This position audits medical records on behalf of hospital clients for denials review, defense audits, disallowed charges and retrospective or concurrent reviews. The Clinical Nurse Reviewer assesses the patient’s plan of care and progress of the patient throughout an acute care admission. The intensity of assessment is situational and appropriate based on payer requirements. This position works independently receiving supervision of work activities from the Manager Case Manager. This position does not supervise other positions.

PCH Values

  • Family-Centered care that focuses on the need of the child first and values the family as an important member of the care team
  • Excellence in clinical care, service and communication
  • Collaborative within our institution and with others who share our mission and goals
  • Leadership that set the standard for pediatric health care today and innovations of the future
  • Accountability to our patients, community and each other for providing the best in the most cost-effective way.

Position Duties

  1. Analysis of Medical record
    • Completes analysis of records against established Milliman criteria, AHCCCS criteria, to determine if patient condition and or care meets specific criteria, including avoidable day studies, managed care or AHCCCS reconsideration/appeals and Medicare appeals.
    • Uses Milliman intensity and severity criteria/guidelines/paths to determine admission status, level of care, and continued provision of services as evidenced by audit.
    • Provides ongoing management of denials and appeals with the Patient Financial Services department. Reports all trends with Case Manager reviews and denial tracking to Manager, Case Management.
    • Performs prospective and retrospective reviews of medical records to identify and or defend charges to include but not limited to defense audits, stop-loss audits, patient inquiry audits, charge-hold audits and biller-requested audits. Creates denial and appeal for medical necessity case that have been denied.
    • Reviews and participates in State Fair Hearings for denials and appeals.
    • This position performs onsite job duties and responsibilities at Phoenix Children’s Hospital, and is viewed as an accessible member of the healthcare team.
    • Applies critical thinking to denial analysis and management.
  2. Develops Collaborative Healthcare Team
    • Collaborates with health care team partners on level of care, identified barriers, and other issues that may impact reimbursement.
    • Establishes a collaborative relationship with physicians, medical directors, nurses and other unit staff, Revenue Cycle management and staff, and payers. Mentors internal members of the health care team on utilization management and managed care concepts.
    • Identifies from review of documentation opportunities for increased education with physicians and the healthcare team.
    • This position performs onsite job duties and responsibilities at Phoenix Children’s Hospital, and is viewed as an accessible member of the healthcare team.
    • Participates in weekly department process improvement meetings.
  3. Regulatory Documentation
    • Participates in various aspects of the revenue-cycle by documenting in AMPFM, SCM, and MIDAS avoidable days, extended length of stay, authorizations, and denials for medical necessity.
    • Performs clinical auditory management in accordance with all state mandate regulations,
    • understands and focuses on key performance indicators, and promptly reports
    • potential denials to health care team.
    • Performs utilization management in accordance with all state mandate regulations,
    • understands and focuses on key performance indicators, and promptly reports
    • potential denials to health care team.
    • Collects data and other information required by payers to fulfill utilization and regulatory requirements.
  4. Utilization Management
    • Attends insurance meetings with Utilization Medical Director and Manager, Case
    • Management as needed. Attends Denial Committee meetings with Hospital Revenue
    • Cycle/Physician Revenue Cycle staff as needed.
    • Communicates with Utilization Medical Director all denials requiring a physician to
    • physician conversation.
    • Obtains and reviews medical necessity denial reports. Analysis and documentation for monthly UMRC report. Reports to Hospital Revenue Cycle denial committee findings of report.
  5. Financial Accountability
    • Participates in various aspects of the revenue-cycle by documenting in AMPFM, SCM,
    • and MIDAS avoidable days, extended length of stay, authorizations, and denials for
    • medical necessity. Completes monthly documentation and financial audits as requested by department manager and director.
    • Provides ongoing management of denials and appeals with the Patient Financial
    • Services department. Reports all trends with Case Manager reviews and denial
    • tracking to Manager, Case Management and Director Case Management & Social Service.
    • Responsible for all facets of inpatient denials due to lack of clinical medical necessity
    • for the Case Management department. Communicates and documents all potential
    • denials and non-certified days.
    • Working knowledge of DRG payment system and impact of ICD-10 on physician documentation.
  6. Provides Excellent Customer Service
    • Establishes a collaborative relationship with physicians, medical directors, nurses and
    • other unit staff, Revenue Cycle management and staff, and payers.
    • Provides cross coverage to all clinical nurse review responsibilities.
    • Provides excellent service routinely in interactions with all customers, i.e. coworkers, patients, visitors, physicians, volunteers, etc.
    • Responds to emails within 24 hours.
    • Clear communication skills with all internal and external customers.
  7. Performs miscellaneous job related duties as requested.

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Position Qualifications

Please review the following qualifications and specify whether you meet each of the requirements listed.
Do you meet this requirement?
Education
1. Bachelors degree in Nursing or a combination of Associate degree in Nursing coupled with 3 years clinical experience. Required
2. Masters degree in Nursing Preferred
Do you meet this requirement?
Experience
1. Minimum of five years of broad clinical experience, predominately in pediatric care. Care coordination, case management, discharge planning and utilization review experience preferred. Required
2. Working knowledge of the financial aspects of third party payers and reimbursement. Required
Do you meet this requirement?
Certifications/Licenses/Registries
1. Current State of Arizona RN license. Required
2. Milliman criteria knowledge. Required
3. Current BLS certification for Healthcare Provider from the American Heart Association. Required
4. Valid AZ Department of Public Safety (DPS) Fingerprint Clearance Card Required
Do you meet this requirement?
Special Skills
1. Excellent communication skills, both verbal and written. Required
2. Effective decision-making /problem solving skills, demonstration of creativity in problem-solving, influential leadership skills. Required
3. Critical thinking skills. Required
4. Moderate to expert computer skills. Required
Physical Requirements & Occupational Exposure/Risk Potential
1. Physical Requirement - Fine Motor Skills (pinching, gripping, etc) Frequently
2. Physical Requirement - Hearing Constantly
3. Physical Requirement - Pushing/pulling Occasionally
4. Physical Requirement - Reaching Occasionally
5. Physical Requirement - Sitting Constantly
6. Physical Requirement - Standing Constantly
7. Physical Requirement - Stooping/crouching/kneeling/crawling Occasionally
8. Physical Requirement - Talking Constantly
9. Physical Requirement - Walking Constantly
10. Physical Requirement - Near Vision Constantly
11. Physical Requirement - Far Vision Constantly
12. Physical Requirement - Use of keyboard, mouse and/or computer equipment Constantly
13. Physical Requirement - Lift up to 35 pounds without assistance Occasionally
14. Occupational Exposure/Risk Potential - Inside office environment Applicable
15. Occupational Exposure/Risk Potential - Airborne communicable diseases Applicable
internal/external
I have reviewed the qualifications, physical requirements and occupational exposure/risk potential for this position and wish to apply