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Coordinate and Track Patient Care

• Act as the liaison between RBH and third-party payers in advocating for the initial (pre-certification) and ongoing medical necessity authorization (concurrent reviews). Provide utilization information to third-party payors and facilitate any physician-to-physician (peer to peer) reviews or expedited appeals.
• Review active medical records to ensure medical necessity documentation requirements are met and escalate documentation or quality care issues if needed.
• Communicate with utilization review (UR), admitting and clinical leadership regarding the quality of documentation within the medical record.
• Collaborate with admitting and clinical leadership in providing education and training to clinical staff in medical necessity documentation.
• Provide documentation training to clinical and admitting staff.
• Provide feedback to clinical staff on the quality of documentation.
• Meet in an ongoing, collaborative manner with the clinician and/or admissions staff to facilitate their knowledge of documentation issues, medical necessity and/or admission criteria.
• Initiate the physician advisory review process as.
• Ensure coverage for all Rogers transitions of care to internal treatment programs by acting as the liaison between admissions, clinical teams, managed care and patient financial services to ensure medical necessity authorization, single-case agreements or self-pay deposits are obtained.
• Inform UR leadership of any sensitive cases or potential cases involving managed care that may lead to contractual arrangements.
• Work with regulatory and/or quality department to identify, investigate or resolve issues that place patients or Rogers Behavioral Health at risk.
  

All care advocates will be assigned one are of primary responsibility, however, will be able to function in all areas, including, but not limited to:

• Pre-certifications/admissions-Complete all responsibilities associated with new admissions, including, but not limited to:
• Ensure all patients admitted to RBH have a current screening per admitting standard work that documents medical necessity.
• Complete all initial authorization requests with third-party payers.
• Review all new admissions to identify any potential coverage concerns for both the current admission and discharge planning.

Resolve or escalate any concerns present on admission to manage risk and ensure quality patient care and cost-quality outcomes.

• Programs-Complete all responsibilities associated with being the assigned care advocate to RBH programs, including, but not limited to:
  • Lead the multi-disciplinary treatment team in ensuring all patients receive quality care with positive cost/quality outcomes.
  • Complete all concurrent reviews with third-party payers.
  • Develop a working relationship with all clinical staff, particularly physicians and managers, to ensure open and frequent communication regarding treatment and case management issues; ensure all information needs are met.
  • Monitor discharge plans to ensure accuracy and completion, including appointment dates, times, and addresses of providers.
  • Collaborate with treatment teams and managed care in the coordination of discharge plans that require a single-case agreement prior to admission to the next level of care.
  • Float-Complete all responsibilities associated with providing coverage for other care advocates whose primary responsibilities are precertification/admission or programs.

Support process improvement initiatives within the UR department.

• Provide assistance to new care advocates with understanding and adhering to standard work.
• Assist in the creation and implementation of new standard work by identifying areas of waste and collaborating with others to identify solution.
• Assist with the collection of data to facilitate continuous improvement.
  

Provide communication and customer service to all stakeholders.

• Provide ongoing communication with clinical teams and admissions/Patient access about the status of cases.
• Assist Patient Financial Services staff with the investigation of any reimbursement problems.
• Communicate with patients and/or family members concerning insurance benefits, authorizations, self-pay arrangements and/or medical necessity denials from third-party payors for continued stays.
• Educate patients and family members regarding any costs of care that may occur in the course of treatment.
• Meet with managed-care companies to establish positive working relationships.

Additional Job Description:

Education/Training Requirements:

• Bachelor's Degree is required; Behavioral Science is preferred.
• Two (2) years previous work experience, office or hospital setting preferred.
• Knowledge of managed care, Medicaid, and Medicare.
• Utilization review experience in a hospital, outpatient or managed care setting preferred.
• Knowledge of the DSM, ICD-10, medical, mental health and chemical dependency diagnosis and treatment process.
• Computer skills are required, including word processing, spread sheets and data processing.
• Knowledge of Joint Commission documentation and medical records standards and ability to maintain accurate records.