Care Coordinator, RN Job at Nexus Health Systems Ltd in Houston

POSITION SUMMARY:

Under the direct supervision of the Manager, Care Coordination – the Care Coordinator supports the coordination of clinical objectives for patient referrals towards exceptional performance. Having financial and clinical accountability over Nexus Health Systems referral protocols, the Care Coordinator works collaboratively with clinical and non-clinical departments such as, but not limited to, Admissions, Utilization Review, Central Business Office and other operational teams as needed – to meet organizational objectives.

JOB SPECIFIC RESPONSIBILITIES:

• Maintain utmost level of confidentiality at all times

• Adhere to health system policies and procedures

• Responsible for promoting adherence to applicable State/Federal laws and regulations and the program requirements of accreditation agencies and Federal/State and private health plans in requests for third party reimbursement

• Provides support to team of Care Coordinators and Utilization Review Nurses

• Develops departmental reports, and routinely distributes to stakeholders as needed

• Provide support to referral evaluation process, and suggest strategies to minimize insurance denials and appeals

• Evaluates incoming referrals and identifying appropriate programming based on clinical presentation

• Develops clinical summaries for incoming referrals to support recommended clinical programming

• Maintains referral correspondence, written and verbal, within a centralized referral database

• Responsible for timely research and evaluation of Medicaid, Medicare regulations, as well as Commercial Payer regulations and changes to optimize the referral evaluation process

• Provides support to the discovery of root cause authorization denials and implement denial management strategies for prevention

• Identifies and interprets trends and patterns for clinical cases, and offer recommendation for resolution

• Participate in denials and appeals as it relates to clinical justification or clinical documentation

• Participate in clinical live reviews, and supports other clinical conversations as needed for the referral evaluation process

• Provides support to on-going quality assurance audits in conjunction with departmental policies

• Supports to telephone calls, ensuring calls are handled with exceptional Customer Service, and escalating to leadership as needed

• Establishes priorities and functional standards, while developing short-term and long-term strategies to meet or exceed KPIs, as the direction of health system objectives changes.

• Meets or exceeds monthly goals as defined for department.

• Supports the identification problematic activity impacting aging, denials, and write-offs for the health system.

• Participates and/or leads departmental meetings or serves as a subject matter expert in executive meetings.

• Recommends and/or implement process improvements with proven and effective data.

• Exemplify excellent Customer Service while communicating internally/externally to stakeholders, to obtain necessary documentation.

• Provides support to the correspondence review process, ensuring action is taken within 48 hours from date of receipt.

• Other duties, as assigned.

POSITION QUALIFICATIONS:

EDUCATION:

• Associate’s degree in nursing (RN), or Bachelor of Science in Nursing (BSN).

EXPERIENCE:

• Two (2) years of healthcare experience, within a clinical review setting.

LICENSURE/CERTIFICATION:

• Certified Revenue Cycle Representative (CRCR), preferred.