Registered Nurse Provider Relations Specialist Full Time
Req #: 18000455
Location: Land O' Lakes, FL
Job Category: Case Management
Organization: FH Connerton LTAC
Potential Referral Bonus: $
Florida Hospital Connerton
At Florida Hospital at Connerton Long Term Acute Care, we deliver meaningful care by getting to know our patients and their families. Our 50-bed hospital is designed to serve individuals who have medically complex illnesses requiring additional weeks of specialized hospital care.
The unique care environment of a long-term acute-care hospital means that our patients and their visitors will spend more time with us than at other hospitals. For that reason, we've designed our hospital to be a comfortable environment. Our specially trained staff are not only experts in providing advanced care, but also have friendly, compassionate personalities that help ease the stress that can be associated with long-term illnesses. The 48,000-square foot, one-story Florida Hospital at Connerton Long Term Acute Care features all private rooms, an operating room for minor inpatient procedures, a chapel, inner courtyard and dining area.
You will be responsible for
- Handles all telephone duties and responsibilities. Promptly reviews any messages left on pre-cert phone and returns calls immediately.
- Consistently answers the phone as outlined in the pre-cert telephone etiquette policy. Assures that the Pre-Certification phone is answered by a “live” person Monday through Friday, 0800-1700 (or per department need) during the days that you are scheduled to work. Prior to the conclusion of each work day scheduled, ensures that the designated system for capturing after hours incoming calls is activated.
- Must ensure all communication with the Admissions Coordinator and Director of Business Development is timely, accurate and complete. Assures there is no confusion on the Case Manger’s part as to what and when they need to follow up for continued stay review.
- Follows the Workflow Process for initiating and completing patient authorizations. Takes full responsibility for following the “Workflow Process” and ensures each referral follows the process, from taking the initial referral until final disposition, acceptance or denial.
- Obtains timely authorization of all patients requiring pre-certification.
- Ensures all policies governing commercial pre-certification and authorization are followed to minimize
- financial risk.
- Evaluates Commercial benefits as verified by the CBO. Reviews benefits with Admissions Coordinator for possible risk and applies/completes written guidelines as necessary to reduce or manage risk.
- Reviews Medicare benefits through VisionShare and Common Working File and accurately accounts for whether the patient has traditional Medicare or a Medicare Advantage plan.
- Accesses Payor Information System to secure Billing and Reimbursement forms and Hospital Contracts to review accommodation codes.
- Applies correct accommodation code through application of the contracted rate per the contract. Reviews rate and accommodation code with the Admissions Coordinator prior to the patient’s registration in HMS and Cerner.
- Communicates daily with Director of Business Development with authorization status.
- Maintains accurate accounting of all referrals for authorization approvals and denials on the designated Daily
- Productivity Worksheet/Log.
- Maintains thorough and complete notes in Cerner UR, notes ensuring that the Case Manager has all
- information necessary to follow up with continued stay review on each commercial patient. Required information including: Authorization Number, Initial approved days and date for follow up with Case
- Manager, Negotiated rate or contracted rate, Name of Insurance Case Manager authorizing, phone and fax number, Completed B&R sent to Case Manager before or on patient admission. Other pertinent information as discussed with Case Manager.
- Verifies Patient Information and Online coverage on Patient Accounts (Pre-Registration)
- Contacts or communicates with the patient and verifies or gathers all demographic, guarantor, employment, insurance, coordination of insurance benefits and provider information. Verifies insurance benefits/coverage, via on-line services only. As necessary, refers patient account to dedicated insurance verification staff if on-line service verification is ineffective or authorizations are necessary.
- Contacts provider’s office to verify or obtain any missing medical, procedure, and diagnosis information
- Enters verification information on individual patient accounts. This includes pre-registration, pre-admits and direct admits.
- Reviews each established inpatient and outpatient account to ensure billing information is complete. Follows established procedures to assure any missing information is obtained prior to the patient’s discharge.
- Refers cases of inadequate or un-verifiable insurance coverage to the Insurance Verifiers. Forwards all Self Pay patients to the Financial Counselors for payment arrangements.
- Enters all information regarding pre-certification, authorizations and Length of Stay information in financial systems.
- Completes all other duties as assigned.
- May cover for Admissions Coordinator and/or Clinical Liaison, as needed.
Case Management :
- Strive to provide excellence in service to hospital staff, patients and families.
- Committed to working as a team to improve Employee satisfaction and engagement scores.
- Demonstrate care for one another and respect for each person’s unique contributions, provides utilization review care that is non-judgmental and non-discriminatory
- Demonstrate respect for human dignity and self-worth
- Respects patient privacy, confidentiality, and dignity by adherence to all HIPAA regulations
- Maintains a professional appearance and manner.
- Consider factors related to patient safety, effectiveness, cost and impact on practice in the delivery of Case Management services. Strives to reduce Medicare and ALOS below established benchmarks
- Assess appropriateness of setting as indicated for medical necessity according to the approved InterQual ISD criteria. Initial and concurrent clinical reviews contain needed elements to sufficiently support Medical necessity.
- Works cases denied by insurance and assist to submit appeals in conjunction with FH Tampa CBO staff
- Utilizes InterQual®ISD & or Milliman criteria to ensure appropriate level of care settings
- Passes Annual Inter-Rater reliability testing for InterQual®
- Ensures appropriate referral of cases to EHR for second level review.
- Identifies and updates current information on community resources.
- Maintains knowledge of current managed care contracts, federal statutes, regulations and procedures
- Applies them in performance of review activities
- Enhances professional knowledge & development through participation in educational programs and in-service meetings. Stays current with journal articles etc.
- Completes annual mandatory education, attend and contributes to 95% of staff meetings
What will you need:
- Follows all facility guidelines outlining standards of personal appearance, attendance and punctuality.
- RN from diploma, Associate or Bachelor’s Degree
- 1 Year Bedside RN in a complex patient care environment (ICU/PCU preferred)
- 1 Year direct experience with third party reimbursement
- 1 Year experience in case management in an acute care environment.
- RN License
- 1 Year experience with precertification of hospital patients (Preferred)
- 1 Year experience working with insurance and/or in a medical office setting(Preferred)
- 1 Year accounts receivables billing and/or collections experience(Preferred)
- Experience with InterQual preferred. (Preferred)
- Case Management Certification (Preferred)