Case Management Representative - OLOL Discharge Billing

The Case Management Representative (CMR) coordinates the day-to-day operations of Utilization Management by providing all insurance companies with the information required to obtain approved days. Directing all denials and appeals to the appropriate person or team. The CMR will submit reviews in a timely manner for payers. Review, index, and/or respond appropriately to payer communication via OnBase. The CMR provides all communication with the insurance company to obtain approved days for the patient’s encounter. Serves as the liaison between various departments in the hospital, including HIM, Business Office, physicians' offices, and Access Services. Coordinates Medical Management Tracker, denial log, and TQ reports. This position is responsible for communicating the essential information to obtain approved for bed days from the insurance company. This communication is the driver for the payment received from the insurance company.

Daily Operations

• Receives calls from payors and records data in a complete and accurate format. Makes written and verbal inquiries to obtain data in a prompt and efficient manner.

• Transcribes data from insurance companies sent via into the electronic medical record.

• Enters data in the electronic medical record to ensure correct billing.

• Provides notification to the Utilization Review team for any denials.

• Sends clinical updates to insurance companies to obtain approval for hospital days.

• Communicates with the Utilization Review Nurse any denials received from the insurance company by fax or verbally.

• Coordinates the daily operations of Utilization Review, obtains the clinical information and forwards to payors to complete for certification. Completes all incomplete certification for all patients.

• Communicates with providers to verify actual dates of services and other information needed to ensure efficient departmental operations.

• Closes the encounter with completion of the bed days table and the record is then sent for billing.

• Coordinates and prepares letters sent to internal and external customers in a prompt and efficient manner.

Quality

• Ensures data entered into the electronic medical record is accurate, maintains reliable data records.
• Maintains source documents and informs appropriate personnel of changes in a timely manner.
• Uses InterQual criteria to assist the Clinical Resource Coordinators in retrieving clinical information and abstracting for weekend Retro Reviews for providers.
• Faxes or updates via payor portal, all completed forms and clinical documentation to providers. Maintains and organizes faxes in an effort to ensure the quality and efficiency of health care service delivery.
• 3. Ensures accuracy of bed days and next review date prior to closing the case.

Other Duties as assigned

• Performs other duties as assigned or requested.