- Performs chart reviews and quality assessments on all patients using MCG criteria and secondary review as directed by Administration and the Medical Staff or as per contract or payer expectation (UR Committee).
- Monitors activity of observation cases to see that the patient is appropriately discharged in a timely manner.
- Ensures the physician writes an order to admit the patient to appropriate level of care along with nursing, verify the physician writes a valid patient status order.
- Documents daily using MCG criteria.
- Initiates Medi-Cal TAR’s at time of admission or as soon as possible thereafter.
- Educates physicians and appropriate hospital personnel regarding criteria for Utilization Management.
- Provides documentation for denial letter and delivers denial letters to patients as directed by UR Committee.
- Researches and prepares appeal for denial claims.
- Identifies inappropriate bed utilization and quality of care problems and refers them to UR Committee.
- Refers appropriate cases to Utilization Management Committee.
- Gives initial review and updates to insurance provider.
- Contacts insurance providers, as required, to ensure reimbursement and verifies post hospital service coverage.
- Interacts with other departments ,eg, Business Office and Admitting.
- Obtains authorization for post-acute care as needed.
- Monitors self-pay patients and refers them to the Health Advocate
- Places patient in the Med-Alert (MAC) system when appropriate.
- Monitors daily patient care to assists in providing quality health care services in own job category to all age groups.
- Collaborates and communicates with multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching, and ongoing evaluation.
- Collaborates/communicates with external case managers.
- Documents relevant discharge planning information on the Interdisciplinary Discharge Planning form and Coordinator Care Plan as appropriate.
- Ensures/maintains plan consensus from patient/family, physician, and payer.
- Facilitates transfer to other facilities.
- Initiates referrals for home health care, hospice, and medical equipment and supplies.
- Manages all aspects of discharge planning for assigned patients as follows: Meets directly with patient/family to assess needs and develop an individualized continuing care plan in collaboration with the physician.
- Refers appropriate cases for social work intervention based on department criteria.
- Intervenes at various points in the patient’s stay to assure that the objectives/goals of the hospitalization is achieved in collaboration with unit Care Coordinators for example timely results of CXR, MRI, labs, etc to prevent delay in discharge.
- Identifies and resolves delays and obstacles in collaboration with the RN Case Managers, nursing and the attending physicians
- Provides information to patients/families relating to patient rights and responsibilities.
- Provides patient/family information about community resources.
- Utilizes community agencies and resources as needed.
- Anticipates and assesses and informs payers of patient's discharge planning needs.
- Collaborates with interdisciplinary and communicates this plan to the payer
- Collaborates with the unit Care Coordinators and interdisciplinary team to facilitate Critical Pathways and to move the patient along the continuum intervening as necessary to remove barriers for timely efficient care delivery.
- Attends interdisciplinary conferences/team meetings where appropriate to discuss patient’s home situation, level of independence and activities of daily living, home management and environment, and anticipated discharge needs for continuum of care.
- Maintains a working knowledge of current Medicare requirements for acute hospitalization, home care, SNF, ECF, and hospice reimbursement.
- Maintains a working knowledge of the changing Medi-cal regulations and other insurance carrier regulations.
- Complies with all applicable laws and regulations.
- Documents in the patient’s hospital record and on Interdisciplinary Discharge Care plan form regarding patient’s home situation and support systems, level of activity, equipment already in the home, and discharge plan including patient/payer preference of agency to ensure communication with the physician and other hospital staff documents appropriately in the electronic medical record.
- Coordinates orders of all physicians involved in discharge arrangements and care.
- Follows medical recommendations and provides service planned to restore patients to optimal social and health adjustment.
- Determines appropriate post-hospitalization facilities (home versus supervised living situation, board and care facility, extended –care facility, or rehabilitation facility), durable medical equipment, post-discharge nursing and/or therapist interventions, social service involvement, and need for assistance with activities of daily living.
- Interviews patients, family members and/or care givers, interface with responsible physicians, and reviews medical records.
- Follows up on the initial patient care plan to determine if any changes are necessary every 3-5 days.
- Negotiates rates for services for pharmaceutical, ancillaries and DME charges with insurance carriers or their representatives for home care provided by Torrance Memorial for items not under contract.
- Enters data including referral for managed care patients, into Home Health System.
- Generates patient referrals for Home Health and Hospice.
- Contacts and assesses facilities and agencies for referrals and determination of their level of care.
- Ensures resources and supplies are available at time of the patient’s discharge.
- Develops and maintains cooperative relationships with hospital personnel, physicians, suppliers and insurance case managers.
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