SUMMARY:  Coordinates and executes the appeal process for all AHS facilities clinical appeals and third party audits. 

DUTIES & ESSENTIAL JOB FUNCTIONS:  NOTE: The following are the duties performed by employees in this classification.  However, employees may perform other related duties at an equivalent level.  Not all duties listed are necessarily performed by each individual in the classification.

1. Actively participate in department meetings and operations, including process development or improvement.

2. 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 admission 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.

3. Collaborates and communicates regularly with contracted Health Plans, Medical/Provider Groups, ancillary vendors, industry-wide organizations (i.e. Department of Managed Health Care, Alameda County Health department, California Children's Services), internal departments and any other providers when appropriate.

4. Communicates with physicians and multidisciplinary health team members to maintain the multidisciplinary team approach to ensure effective resource utilization and an appropriate level of care.

5. Coordinates all utilization review functions, including response to payor requests for concurrent and retrospective review information including Medicare and MediCal regulations/requirements; ensures the appropriate level of care is assigned and documented on all patient medical records.

6. 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.

7. 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.

8. Ensures all applicable department and regulatory targets for productivity and department performance process improvements in the area of denials are attained (e.g., readmissions, throughput, LOS).

9. Identifies and documents quality incidents.

10. Initiates the appeal process, at the direction of the Supervisor and/or physician advisors, until the case is overturned, appeal options are exhausted, or the decision is made to discontinue the 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.

11. Perform all other duties as assigned.

12. Performs utilization concurrent and/or retrospectively reviews all the patients in caseload in the following areas: admission criteria for medical necessity and appropriateness of care, continued stay criteria for medical necessity and appropriateness of care, Resource Management issues, other issues including concerns involving under/over utilization, avoidable days and quality issues.

13. Responsible for all incoming and outbound clinical requests, questions, concerns and complaints.

14. Tracks and trends progress and outcomes of denial and appeal processes and compiles reports for division and AHS leadership.

MINIMUM QUALIFICATIONS:

Preferred Education: Master's in Nursing.

Preferred Licenses/Certifications: Certification in Case Management, CCMC or ACM.

Required Education: Bachelor's of Nursing,

Required Experience: 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.

Required Licenses/Certifications: Active licensure as a Registered Nurse in the State of California, Active BLS - Basic Life Support Certification issued by the American Heart Association. Other advanced life support certifications may be required per unit/department specialty according to patient care policies. CPI -Crisis Prevention Intervention Training (required for all positions at John George Psychiatric Pavilion; and certain positions in the Emergency Department).