The Lead Care Coordinator will provide hands-on expertise to other team members as needed to help ensure that every patient receives the right type of care, at the right time in the right setting, every day. The Lead will oversee a manageable patient caseload and utilize medical necessity screening tools, such as InterQual or MCG criteria, to complete initial and continued stay reviews in determining appropriate level of patient care, estimation of the patient's expected length of stay and securing insurance authorization for services provided.
The Lead follows the Case Management process per department policy and as defined in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review. Responsibilities Leads patient case load and acts as a resource for the staff and Nurses regarding Utilization Management (UM) and/or Case Management department process and payer processes as needed. Acts as a first point of contact for clinical clarification/education.
Works collaboratively with department leadership and staff to ensure that work processes are well-ordered and managed appropriately. Provide backup to staff, other departmental teams and/or management staff, as needed. Supports and actively participate in department performance improvement, assist with the development, implementation and monitoring of processes and procedures to facilitate improvement.
Participates in monitoring and data analysis of utilization metrics. Monitors of staff workload, creating assignments, reviewing productivity, conducting quality reviews, advising with peer-to-peer appeals, and advising with concurrent denials. Reviews concurrent denials and works with the payer and physician to overturn the denial; Assists in arranging peer to peer conferences.
Monitors patient length of stay and collaborates with physicians, care coordinators and multidisciplinary team to ensure resource utilization is appropriate for patients’ overall needs Consults with medical staff, care team and care coordinators as necessary to resolve immediate progression of care barriers through appropriate administrative and medical channels. Identifies and documents delays in service, progression of care or patient flow barriers using the Avoidable Days tool in the Utilization software program.
Processes confidential data and information according to appropriate organization and federal guidelines. Maintains appropriate documentation in the Utilization software system on each patient as per the department “Medical Necessity and Clinical Review Process” department guidelines. Functions as an advocate, and contact person for the care team, patient/family when communicating with payers, and or outside agencies to assure continuity of care, optimal clinical resource outcomes, and appropriate financial management for the patient and the organization.
Education Bachelor's Degree Nursing - minimum Master's Degree Nursing - preferred Experience 3 years Acute Nursing experience - minimum 2 years Case Management experience - minimum Licenses and Certifications RN State License - Upon Hire minimum Issued by the State of California Basic Life Support (BLS) - Upon Hire minimum Certified Case Manager - 2 years preferred Experience and certification in case management preferred