HCA, Hospital Corporation of America Manager, Case Management Concurrent Denials (RN) in Franklin, Tennessee
HCA, a Fortune 100 company with more than 200,000 employees, is one of the nation's leading providers of healthcare services, operating over 170 locally managed hospitals and over 100 freestanding surgery centers in 20 states and the United Kingdom. With its founding in 1968, HCA created a new model for hospital care in the United States, using combined resources to strengthen hospitals, deliver patient-focused care and improve the practice of medicine. HCA is a learning healthcare system that uses more than 27 million annual patient encounters to advance science, improve patient care and save lives. HCA has been named one of the world's most ethical companies for eight years in a row. At HCA, we are driven by a single goal: the care and improvement of human life.
The Manager, Case Management Concurrent Denials is primarily responsible for carrying out the day to day review and management of concurrent denials for HCA facilities. Daily management may include application of InterQual, discussion with facility Case Management and Physicians, facilitate peer-to-peer process, interaction with payor, external physician advisors, PCA and Parallon revenue cycle departments. The Manager Concurrent Denials must be a subject matter expert in acute care utilization review and denial mitigation with a strong clinical background. In addition, the Manager Concurrent Denials must have a working knowledge of URAC & NCQA guidelines, InterQual, payor processes and regulations related to the utilization review process. Strong communication skills are required and utilize payor contracts and/or manuals to develop concurrent appeal strategies. As an essential element to the overall success of the Case Management Program, the Manager Concurrent Denials should consistently demonstrate a strong work ethic and commitment to excellence. This position requires the ability to function with moderate supervision in a rapidly changing environment and to serve as a subject matter expert to the Case Management departments within HCA · Work independently as well as collaboratively with facilities to ensure complete and timely follow through on concurrent denials · Become a subject matter expert on contract language as they pertain to denials, i.e., notification, utilization management, discharge planning, and the issuance of a denial · Act as an InterQual subject matter expert and apply that knowledge when reviewing concurrent denials · Evaluate denials, i.e., contractual vs. technical vs. medical necessity · Interact with payor nurse reviewers to discuss and challenge concurrent denials issued as appropriate and escalate to the Plan Directors, Managers, and Supervisors when applicable · Work closely with Case Management Physician Champion at each facility as well as contracted external physician advisors to overturn concurrent denials · Document denial and appeal activity timely and accurately in Midas per HCA Case Management education · Identify process improvement opportunities and assist with the development, implementation, monitoring, and revision of action plans to reduce the number of denials · Provide feedback to assist with denial reduction strategies · Understand healthcarereimbursement, the benefit provisions of an insurer, state insurance requirements, URAC and NCQI standards· Remain current in evidence-based best practices · Assists in the development of Utilization Management Program tools needed to streamline processes and reporting
BSN Strong clinical background with 4-6 years acute care nursing experience required Relevant case management / utilization review experience required Knowledge of case management, discharge planning, and utilization review practices and ability to incorporate current trends successful Understanding of governmental and JCAHO regulations Must have strong clinical, analytical, written, verbal and presentation skills Ability to communicate effectively in oral, written and electronic formats Ability to establish and maintain collaborative and effective working relationships with a focus on the importance of teamwork
Job: *Case Management
Title: Manager, Case Management Concurrent Denials (RN)
Location: Tennessee-Franklin-Corporate Cool Springs
Requisition ID: 10215-22672