Auth Coordinator - Case Manager RN

JOB SUMMARY

Authorization Coordinator collaborates with Insurance verification, insurance CM, Hospital Case Manager UR/transition Planner and physicians to facilitate obtaining authorizations. The individual’s responsibilities include but are not limited to the following actions : a) Follow up on patient accounts when authorization for stay is required , Fax numbers to Send clinical reviews b) Follow up on each account during the stay and on discharge for authorization - document in the electronic system, c) Escalate any potential disputes or denial of accounts to Director of Case Management or designee d) Trends disputed e) Coordination of concurrent denials/preparation for appeal for retrospective denials f) other duties as assigned

DUTIES AND RESPONSIBILITIES

Essential Job Duties

• Validates patient’s demographic and payer information with patient/family and notifies Patient Access immediately if any corrections are needed
• Validates that all commercial/managed care discharges have an authorization for status and level of care provided and notifies Director of Case Management (DCM) or designee of variances
• Cases that require authorization are obtained daily by fax or phone and documentation is completed daily
• Escalate discharged cases at end of day that have no authorization or notification of dispute is provided by payor
• Concurrently make sure all clinical needed by payors and updates are provided by alerting Case Manager assigned to case and escalating to DCM if not completed timely
• Trend dispute/denial potential to DCM or designee by failure points in revenue cycle
• Prepare denial information for UR Committee, Denial and Revenue Cycle Meetings
• Collaborate with Patient Access, Case Management, Managed Care and Business office to improve concurrent review process to avoid denial or process delays in billing accounts
• Adheres to federal, state, and local regulations and accreditation requirements impacting case management scope of services
• Adheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation
• Manages and operates equipment safely and correctly.
• Interacts professionally with patient/family and involves patient/family in the formation of the plan of care.
• Acts on performance improvement issues identified during CQI meetings.
• Actively participates in Case Management Committee, CQI, varying team meetings and other meetings, as appropriate.
• Maintains and respects confidentiality of patient/physician/personnel information.
• Demonstrates an ability to be flexible, organized and function under stressful situations.
• Maintains a good working relationship both within the department and with other departments.
• Consults other departments as appropriate to collaborate on patient care and performance improvement activities.
• Accurately determines type of assistance/setting/resources necessary for the patient/family and provides appropriate resources/assistance/list of facilities.
• Documentation meets current standards and policies.

PROFESSIONAL REQUIREMENTS

• Reports to work on time and as scheduled, completes work within designated time.
• Adheres to scheduling requests of the department (Works weekends, no “special days off”, no exceptions, unless in school).
• Adheres to the Standards of Conduct of Baylor Scott and White at Sunnyvale while representing the organization in a positive and professional manner.
• Communicates the mission, ethics and goals of the facility, as well as the focus statement of the department and complies with all organizational policies regarding ethical business practices.
• Utilizes computerized punch time system correctly
• Completes annual education requirements and maintains regulatory requirements.
• Adheres to dress code, appearance is neat and clean and wears identification while on duty.
• Completes in-services and returns in a timely fashion and has not missed any mandatory in-services.
• Attends at least 8 staff meetings annually, is responsible for information presented at monthly staff meetings that he/she is unable to attend.
• Actively participates in performance improvement and continuous quality improvement (CQI) activities.

REGULATORY REQUIREMENTS

• RN with current Texas Nursing license
• 2 or more years with Medical Surgical Nursing experience -preferably Case Management experience

LANGUAGE SKILLS

• Able to communicate effectively in English, both verbally and in writing.
• Additional languages preferred.

SKILLS

• Basic computer knowledge.

PHYSICAL DEMANDS

• For physical demands of position, including vision, hearing, repetitive motion and environment, see following description.

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.