1. Reviews admissions (physician orders, emergency room documentation, diagnostic test) for admission status based on approved utilization management criteria sets.
2. Uses Interqual effectively in all admissions and concurrent reviews.
3. Confers with the admissions department and/or emergency room staff regarding admission status (in-patient vs observation) of patient as necessary.
4. Conducts admission, concurrent, and discharge review for insurers and other agencies in order to obtain authorization and length of stay assignment when require. Does this in time frame designated by each insurance, keeps up to date on each insurance requirements.
5. Performs admission review and discharge screening within 24 hours of admission as outlined in the Case Management plan, screens on a daily basis all new patient admissions to identify patients in potential need of comprehensive discharge planning .
6. Familiarizes self with assigned patients medical history, keeps track of major sequence of event in current hospitalization and knows the anticipated DRG, length of stay, and transfer and/or discharge date.
7. Completes the assessment within 72 hours of admission for each patient. Completion of assessment includes interview with the patient, family or other caregivers, and also may utilize chart information from previous stays
8. Include in the evaluation the patients need for appropriate post-hospital services and the availability of such services, when appropriate providing a list to the patient and document that the list was given to the patient and/or the patient’s representative, ensuring the evaluation is in the patient’s medical record.
9. Identifies and coordinates making appropriate arrangements for patient post-discharge treatment at home or at post-acute care facilities including but not limited to: home health, nursing home, SNF, Rehab, LTAC, Hospice, Behavioral Health, & DME, this includes contacting community providers/agencies involved in the discharge plan in preparation of discharge.
10. Makes additional notes and documents conversations with other members of interdisciplinary team These notes may also include conversations with caregivers, families, and other support systems involved with the care of the patient
11. Use quality and resource measures relevant to patients’ goals of care and treatment preferences in the discharge planning process. This is aimed to increase the use of quality data as a decision-maker in selecting post-acute providers.
13. Checks voice mail and emails periodically throughout the day and before leaving each day. Handles insurance review requests and patient related calls and removes the messages in a timely manner
14. Responsibilities specific to Quality Assurance include performing surveillance and data collection as directed for trend recognition and development of effective actions/plans.
15. Consults social services as necessary per assessment findings or MD orders.
16. Documentation: Documents all authorizations in HMS, Documents data in CM logs, including but limited to: Denials, Readmissions, Avoidable Days, 1 day stays, discharge disposition, CFO census update. Documents DC plan updates and family involvement in nurses notes
17. Identify high-risk patients within caseload, document key data elements for use in hospital’s re-admission data. When applicable, the new discharge plan should incorporate resources that help remedy any issues identified.
18. Work with a readmitted patient or family members to try and identify the root cause of readmission, this can include capturing information from post-acute providers or vendors a patient used after a previous discharge.
19. Arrange and ensure that telephone contact occurs within 72 hours of discharge.
20. Attends daily report with supervisor and IDT meetings twice as week as scheduled. Reports LOS, medical or social problems with patients and is helpful in creating discharge plans and overcoming any obstacles that may occur.
21. Keeps physicians informed about current patient status, consulting with them on patient progress toward expected outcomes.
22. Appeals all denials within the allotted time frames.
23. Communicates with the business office as requested on the status of authorizations, appeals, retrospective reviews, correct dates of stay, level or care and other information requested.
24. Coordinates discharge and/or transfer arrangements in a timely and thorough manner, ensuring all necessary clinical information is sent to the next provider and all necessary forms are signed and placed on chart.
25. Stays abreast of pertinent laws/rules, regulations and researches for further reference i.e. Centers for medical and Medicaid Services.
26. Any other duties assigned as needed to help drive our Mission and abide by our organizations values.
Acadian Medical Center has a total of 49 licensed beds
All private rooms with private baths.
We offer a 24 hour physician-staffed Emergency Room
And provide a comprehensive list of Inpatient
And Outpatient services including: ICU, Physical Therapy, OB/GYN,
Cardiology, Pharmacy, Laboratory Services, Urology, Social Services,
ENT, Cardiac Rehab, Pediatrics, Internal Medicine, Family Practice,
Podiatry, Ophthalmology plus General and Orthopedic Surgery,
Dietary and Respiratory.
Radiology Services include MRI, Dual Head Nuclear Medicine and a 64
Slice CT with computed radiology.
Our Mission "Making Communities Healthier"
