Care Management Clinical Appeals Specialist, Oakland, CA
Care Management Clinical Appeals Specialist (rev 072216)
Highland General Hospital · HGH Utilization Management
Business Professional & IT
Full Time, Day
Req # 17818
Alameda Health System (AHS) is the East Bay's premier patient and family-centered care system. Our trauma center and teaching hospital are considered among the best in the country. We are committed to continually improving health through individual patient experiences. Our mission, Caring, Healing, Teaching, Serving All, speaks to the vital role we play in the community and the critical responsibility we accept in promoting wellness, eliminating disparities and optimizing the health of a diverse East Bay.
It is a New Day in health care, and it's a New Day at Alameda Health System.
If you have expert knowledge on how to overturn denials through effective appeals, you understand payer requirements and know medical necessity like the back of your hand then Alameda Health System wants to hear from you! As a Clinical Appeals Specialist, you will play a key role in optimizing Highland Hospital's reimbursements for the care we provide to our patients. With your keen eye for detail and utilization review skills, you will help us recapture lost revenue and improve performance.
- 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.
- Tracks and trends progress and outcomes of denial and appeal processes and compiles reports for division and AHS leadership 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.
- Communicates with physicians and multidisciplinary health team members to maintain the multidisciplinary team approach to ensure effective resource utilization and appropriate level of care.
- Coordinates all utilization review functions, including response to payor requests for retrospective review information including Medicare and MediCal regulations/requirements; ensures the appropriate level of care is assigned and documented on all patient medical records.
- 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.
- 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.
Bachelor of Nursing. Master of Nursing preferred.
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.
Active licensure as a Registered Nurse in the State of California, Active BLS - Basic Life Support Certification issued by the American Heart Association. CPI -Crisis Prevention Intervention Training. Certification in Case Management, CCMC or ACM is preferred.
Alameda Health System offers a comprehensive benefit package including employer paid health coverage, voluntary plans and retirement savings options. Relocation assistance may be available.