Job Description

The individual in this position works under direction of RN Case Manager and/or Social Worker. The individual’s

responsibilities include but are not limited to the following actions : a) Follow up on patient accounts when authorization for

stay is required , Fax numbers to Send clinical reviews b) Follow up on each account during the stay and on discharge for

authorization - document in the electronic system, c) Escalate any potential disputes or denial of accounts to Director of

Case Management or designee d) Trends disputed claims by at least payor and physician e) assist in obtaining authorization

for patient discharged to Skilled Facilities or other post-acute care that require authorization f) other duties as assigned

General Functions

Utilization Management

 Validates patient’s demographic and payer information with patient/family and notifies Patient Access

immediately if any corrections are needed

 Validates that all commercial/managed care discharges have an authorization for status and level of care

provided and notifies Director of Case Management (DCM) or designee of variances

 Cases that require authorization are obtained daily by fax or phone and documentation is completed daily

 Escalate discharged cases at end of day that have no authorization or notification of dispute is provided by payor

 Concurrently make sure all clinical needed by payors and updates are provided by alerting Case Manager

assigned to case and escalating to DCM if not completed timely

 Trend dispute/denial potential to DCM or designee by failure points in revenue cycle

 Prepare denial information for UR Committee, Denial and Revenue Cycle Meetings

 Collaborate with Patient Access, Case Management, Managed Care and Business office to improve concurrent

review process to avoid denial or process delays in billing accounts (85% daily, essential)

Transition Management

 Follow up on Authorization for post-acute services

 Makes referrals for post-acute services under the direction of the RN Case Manager or Social Work (SW) staff

utilizing the Tenet Case Management documentation system

 Follow-up if referral requires an authorization by payor to discharge the patient

 Completes tasks as assigned by RN or LVN Case Manager and/or SW staff

 Makes copies, send faxes and complete phone calls to arrange post-acute services and to ensure that appropriate

hospital information is communicated to post-acute providers

 Documents all referrals and tasks in the Tenet Case Management documentation system per Tenet policy 

Provides Important Message follow up letter to Medicare beneficiaries per Tenet policy and under the direction of

the RN Case Manager or SW (10%daily, essential)

Compliance

 Adheres to federal, state, and local regulations and accreditation requirements impacting case management scope of

services

 Adheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of

Participation and Tenet policies (5% daily, essential

MINIMUM EDUCATION: High School diploma or equivalent required.

PREFERRED EDUCATION: Associate or Bachelor’s degree

MINIMUM EXPERIENCE: Must have excellent organizational skills, excellent verbal and written communication

skills, demonstrated problem solving skills, and computer literacy.

PREFERRED EXPERIENCE: Acute hospital experience. Data Analytic skills.

REQUIRED CERTIFICATIONS/LICENSURE: N/A

PREFERRED CERTIFICATIONS/LICENSURE: Paramedic, EMT or Nursing Assistant

REQUIRED COURSES/ COMPLETIONS: N/A

PATIENT POPULATION/AGES SERVED: (√) Check all that apply

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Baptist Health System Hospital is committed to providing exceptional patient care in a supportive and collaborative environment. As a member of our team, you will have the opportunity to work with advanced technology and be part of a healthcare community dedicated to making a positive impact on the lives of our patients.

At Baptist Health System, we understand that our greatest asset is our dedicated team of professionals. That’s why we offer more than a job – we provide a comprehensive benefit package that prioritizes your health, professional development, and work-life balance. The available plans and programs include:

• Medical, dental, vision, and life insurance
• 401(k) retirement savings plan with employer match
• Generous paid time off
• Career development and continuing education opportunities
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance

Note: Eligibility for benefits may vary by location and is determined by employment status