The individual in this position is responsible to facilitate effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patientï¿½s resources and right to self-determination.The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity.This position manages medical necessity process for accurate and timely payment for services which may require negotiation with a payer on a case by case basis. This position integrates national standards for case management scope of services including:
Utilization Management services supporting medical necessity and denial prevention
Coordination with payers to authorize appropriate level of care and length of stay for medically necessary services required for the patient
Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
Education provided to payers, physicians, hospital/office staff and ancillary departmentsrelated to covered services and administration of benefits
The individualï¿½s responsibilities include the following activities: a) accurate medical necessity screening and submission for Physician Advisor review, b) securing and documenting authorization for services from payers, c) managing concurrent disputes, d) collaborating with payers, physicians, office staff and ancillary departments, e) timely, complete and concise documentation in the Tenet Case Management documentation system, f) maintenance of accurate patient demographic and insurance information, g) identification and documentation of potentially avoidable days, h) identification and reporting over and underutilization, i) and other duties as assigned.
Required qualifications include an active Registered Nurse license with at least two years acute hospital or Behavioral Health patient care experience. BSN preferred (unless required * if Magnet Hospital). Accredited Case Manager (ACM) preferred. Required skills include demonstrated organizational skills, excellent verbal and written communication skills, ability to work in a fast paced environment, critical thinking and problem solving skills and computer literacy.
Job: Case Management/Home Health
Primary Location: Delray Beach, Florida
Facility: Delray Medical Center
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Internal Number: 2005028277
About Delray Medical Center
“Tenet Healthcare Corporation is a diversified healthcare services company with 115,000 employees united around a common mission: to help people live happier, healthier lives. Through its subsidiaries, partnerships and joint ventures, including United Surgical Partners International, the Company operates general acute care and specialty hospitals, ambulatory surgery centers, urgent care centers and other outpatient facilities. Tenet's Conifer Health Solutions subsidiary provides technology-enabled performance improvement and health management solutions to hospitals, health systems, integrated delivery networks, physician groups, self-insured organizations and health plans.