Care Management Clinical Appeals Specialist
Company: Alameda Health System
Location: San Leandro
Posted on: January 27, 2023
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Job Description:
Summary SUMMARY: -Coordinates and executes the appeal process
for all AHS facilities clinical appeals and third party audits.
DUTIES & ESSENTIAL JOB FUNCTIONS: - NOTE: The following are the
duties performed by employees in this classification. - However,
employees may perform other related duties at an equivalent level.
- Not all duties listed are necessarily performed by each
individual in the classification.
1. Actively participates in department meetings and operations
including process development or improvement. 2. Assures clinical
interventions are appropriate for the admitting diagnosis and
reflect the standard of care, as defined by the medical staff and
the organization; utilizes clinical knowledge and defined standards
of care to proactively identify inappropriate admit status based on
identified criteria and ensures the patient is registered at the
appropriate level of care; Utilizes McKesson Interqual - clinical
guidelines; refers questionable cases to the CM Manager or
physician advisor for determination. mso-fareast-font-family:"Arial
Unicode MS""> 3. Collaborates and communicates regularly with
contracted Health Plans, Medical/Provider Groups, ancillary
vendors, industry wide organizations (i.e. Department of Managed
Health Care, Alameda County Health department, California
Children's Services), internal departments and any other providers
when appropriate. 4. Communicates with physicians and
multidisciplinary health team members to maintain the
multidisciplinary team approach to ensure effective resource
utilization and appropriate level of care. 5. Coordinates all
utilization review functions, including response to payor requests
for concurrent and retrospective review information including
Medicare and MediCal regulations/requirements; ensures the
appropriate level of care is assigned and documented on all patient
medical records. 6. Coordinates with Care Management team when
cases do not meet criteria; coordinates denials with the attending
physician and the Care Management physician advisor; prepares case
reports; documents treatment plan, progress notes and discharge
summary related information as required by Medicare, MediCal, Title
22 and other mandated regulations according to Department
standards. mso-fareast-font-family:"Arial Unicode MS""> 7.
Develops, collects, trends and analyzes data relevant to the
utilization of healthcare resources including but not limited to
avoidable/variance days, readmissions, one-day stays, DRGs, LOS. 8.
Ensures all applicable department and regulatory targets for
productivity and department performance process improvements in the
area of denials are attained (e.g., readmissions, throughput, LOS).
9. Identifies and documents quality incidents. 10. Initiates the
appeal process, at the direction of the Supervisor and/or physician
advisors, until the case is overturned, appeal options are
exhausted or decision is made to discontinue process; assumes the
responsibility for coordinating and appealing clinical denials per
department policy; develops any appeal letters to substantiate the
medical necessity for admission or continued stay using evidence
from the medical record and clinical review tools, as well as input
from the attending physician and/or Physician Advisor, complies
with all submission time frames and other guidelines outlined by
the third party payers and auditors. 11. Perform all other duties
as assigned. 12. Performs utilization concurrent and/or
retrospectively reviews all the patients in caseload in the
following areas: admission criteria for medical necessity and
appropriateness of care, continued stay criteria for medical
necessity and appropriateness of care, Resource Management issues,
other issues including concerns involving under/over utilization,
avoidable days and quality issues. 13. Responsible for all incoming
and outbound clinical requests, questions, concerns and complaints.
mso-fareast-font-family:"Times New
Roman";mso-ansi-language:EN-US;mso-fareast-language:
EN-US;mso-bidi-language:AR-SA"> 14. Tracks and trends progress
and outcomes of denial and appeal processes and compiles reports
for division and AHS leadership.
mso-fareast-font-family:Calibri;mso-fareast-theme-font:minor-latin;mso-ansi-language:
EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA">
MINIMUM QUALIFICATIONS: Preferred Education: Master's in Nursing.
Preferred Licenses/Certifications: Certification in Case
Management, CCMC or ACM. Required Education: Bachelor's of Nursing,
Required Experience: Five years of acute care nursing including
medicine/surgery, ICU, telemetry or Five years of Case Management
experience in an acute setting or utilization review at a medical
group or health plan. mso-fareast-font-family:"Times New
Roman";mso-ansi-language:EN-US;mso-fareast-language:
EN-US;mso-bidi-language:AR-SA"> Required
Licenses/Certificationsmso-fareast-font-family:"Times New
Roman";mso-ansi-language:EN-US;mso-fareast-language:
EN-US;mso-bidi-language:AR-SA"> : Active licensure as a
Registered Nurse in the State of California, Active BLS - Basic
Life Support Certification issued by the American Heart
Association. Other advanced life support certifications may be
required per unit/department specialty according to patient care
policies. CPI -Crisis Prevention Intervention Training (required
for all positions at John George Psychiatric Pavilion; and certain
positions in the Emergency Department).
Additional Information This is a hybrid role
Patient Financial Services
Patient Financial Svcs - Facil
Full Time
Day
Business Professional & IT
FTE: 1
Keywords: Alameda Health System, San Leandro , Care Management Clinical Appeals Specialist, Executive , San Leandro, California
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