Genesis HealthCare Careers

Pre-Certification RN Coordinator (Full Time)

Foothill Ranch, California
Nursing - Clinical/Nurse Consultant

Job Description

POSITION SUMMARY: The Care Coordinator RN is responsible for the promotion of quality, cost-effective services and care through a collaborative process that coordinates, monitors, and evaluates services accorded to all transitional patients admitted to the assigned Center. The Care coordinator identifies practice patterns within the Center that contribute to high resource utilization and monitors changes in status that could lead to hospital readmission and report to nursing. He/she develops and implements discharge plan to include responsibilities of nursing, rehab and social service staff and communicate plan to payor, staff and customer/family as necessary


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.

3. Education:
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.

4. Documentation:
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.

5. Professional
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




SPECIFIC EDUCATIONAL/VOCATIONAL REQUIREMENTS:1. Graduate of an accredited School of Nursing with current RN licensure in the state in which employment occurs required. Bachelor's Degree in Nursing preferred. Certified Case Management (CCM) or related clinical certifications also preferred. 2. Five years of recent clinical nursing experience required. Prior experience in utilization review, case management or discharge planning required.3. Experience in rehabilitation nursing, acute care and/or the insurance field preferred. Two years full time experience in case management which includes service to short/long term facility based clients preferred.4. Valid driver's license and automobile with appropriate insurance required.

Position Type: Full Time
Req ID: 290422
Center Name: Genesis HealthCare