Genesis HealthCare Careers
Pre-Certification RN Coordinator (Full Time)
1. Financial Role:
a. Provide current, accurate and complete clinical information to payor
b. Be familiar with third party reimbursement, insurance coverage and contract requirements
c. Communicate financial and statistical information to Genesis ElderCare Center, Business Office and Managed Care Billing
d. Negotiate for appropriate continuation of length of stay or extension of services and appropriate Level of Care rates
e. Assess available resources to optimize resource utilization
f. Facilitate obtaining payor authorization for recommended treatments, procedures, supplies, equipment and excluded medications
g. Assist in identifying alternatives/solutions to uncovered services
h. Assist Center in responding to denial of payment by providing clinical information that substantiates the need for continued coverage.
2. Resource Management:
a. Assess patient/family risk factors as it relates to resource utilization: chronicity, complications and comorbidity and identify barriers to a timely discharge
b. Act as resource to physicians, NPs and Treatment Team to identify alternate, cost-effective treatment options
c. Review Pre-Placement Assessments to identify costly treatments, supplies or services and assist staff in obtaining authorizations
d. Identify overuse or resources such as rehabilitation therapy, diagnostic studies, nonformulary medications and medical supplies
e. Review Admission orders on all managed care patients for appropriateness and notify responsible personnel when duplicate services are ordered
f. Verify that the Care Management Client form is correct for contracted vendors to be used for needed patient services
g. Clearly communicate contract inclusions and exclusions to Treatment Team as necessary
h. Utilize standard review forms and language for Treatment Team documentation to comply with payor requirements
i. Maintain and submit utilization data/information/reports as requested by Managed Care Operations or the Manager of Internal Care Management
j. Advise Center of changes in reimbursement mechanisms
k. Consult Social Worker immediately for all identified social, customer/family problems that are identified as barriers to a timely, appropriate discharge.
a. Communicate identified educational needs to Manager of Internal Care Management or Regional Implementation Coordinator
b. Maintain a current and comprehensive knowledge of third party payors, insurance reimbursement and the appeal and denial process
c. Educate staff in cost containment strategies
d. Explain covered services and resources to Center staff
e. Instruct Center staff in terminology, language and format that is preferred by Managed Care Operations for reporting.
a. Clearly document all concurrent review and discharge planning information sent to payor
b. Submit timely, accurate and complete patient and payor information to Managed Care Billing and the Center business office
c. Forward Monthly Inpatient Tracking Summary and Managed Care Communication Form to Managed Care Billing in a timely manner
d. Maintain comprehensive case management records on all customers that reflects authorizations, extensions, levels of care, dates of service and rates approved by the payor to include name, phone and date of payor case manager's authorization;
e. Organize information on Managed Care patients to support easy retrieval of data;
f. Submit confidential reports as requested by Management.
a. Promotes the Network internally and externally.
b. Maintain professional image and demeanor.
c. Comply with all Genesis Health Ventures personnel policies.
d. Perform other duties as requested
Position Type: Full Time
Req ID: 290422
Center Name: Genesis HealthCare