Easter Seals Jobs

JOB DESCRIPTION

Reviews medical admission record & continued stay for plan of care, appropriateness of timeliness of services

RESPONSIBILITIES

 Responsible for all aspects of the concurrent review program, insurance certification, and authorization process for all Psychiatric or Chemical Dependency Inpatient Units (subject to assignment by management) and for all aspects of the initial review on an as needed basis

 Develops rapport with and daily working relations with CPEP or Stuyvesant Square Admitting and Inpatient clinicians to insure ongoing, comprehensive clinical information if both documented and available in timely fashion to facilitate initial clinical reviews, pre-certifications and authorizations to admit to inpatient as well as continuing stay review approvals and authorizations

 Maintains daily communications and documentation with all Hospital Insurance Verification and Patient Accounts staff to insure timely verification of patient insurance and insurance status

 Coordinates insurance authorizations through provision of appropriate clinical information (confirmed by documentation) to insure optimization of inpatient authorizations. Develops ongoing relationships with insurance provider case managers to maximize authorization potential.

 Communicates with inpatient clinical staff to insure timely discharge planning is in place when insurance authorizations expire and patients become financially burdensome to the organization; seeking clinically appropriate alternatives from treating physicians, social workers, nursing staff

 Monitors and coordinates the designation of alternative level of care with the UM Manager and/or Program Manager and Physician.

 Notifies and coordinates inpatient services when delays are noted in order to reduce length of stay and improve quality of care

 Responsible for data and report generation of providers as well as regulatory agencies, as needed for Utilization Management activities

 Demonstrates the knowledge and skills necessary to provide care based on physical, psychosocial, educational, safety, and related criteria, appropriate to the age of the patient served in assigned area

 Utilizes Hospital Mainframe programs, CANOPY Care Management System, and TRAC effectively and coordinates updates with Insurance Verification, Social Work management, and Patient Accounts as appropriate

 Refers appropriate cases to external agency (NCO) for second level of appeal.

 Prepares concurrent review information for Review/Appeals Nurses

 Meets timeframe for reviews/appeals as specified by Insurance/State and Federal regulation

 Performs all aspects of the concurrent review program as well as initial pre-certification/authorization as needed to insure patient admission is approved

 Identifies and refers to the UM Manager &/or Administrator and/or Physician problematic utilization and quality issues

 Responsible for the maintenance of accurate data for approvals, denials and appeals (in coordination with UM Manager and management).  Prioritizes insurance Request/Denials when received in the department as per protocol; Responds to Insurance requests for information to prevent denials/recover payment.  Requests or provides Medical Records as required for appeals, On/Off-site Insurance reviews in both normal pursuit of regular UM activities.  Obtains/Prepares Medical Records and other documentation for Photo Copying Service, outside 2nd party / Discharge Appeals in normal pursuit of regular UM activities.  Assumes responsibility for Denial and Appeal processing and satisfaction as requested by UM Manager, or Departmental Manager.  In relationship to UM Insurance verification; authorizations and approvals; denials and appeals, will assist in the processing of mail.

 Supervises support staff as needed

QUALIFICATIONS

• Masters degree preferred with experience in related field

• Computer literate: must know MS Word, Excel, Access, and be able to learn work-related applications.

• Highly organized, articulate, with demonstration of sound judgment, mature attitude, excellent interpersonal and communication skills.

• Requires minimal supervision.

Non-Bargaining Unit, B3Y - Psychiatry Central Intake RV - BI, Mount Sinai Beth Israel

REQUIRED SKILLS

Microsoft Office Suite

ABOUT US

Strength Through Diversity

The Mount Sinai Health System believes that diversity, equity, and inclusion are key drivers for excellence. We share a common devotion to delivering exceptional patient care. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education, and advancement as we revolutionize medicine together. We invite you to participate actively as a part of the Mount Sinai Health System team by:

• Using a lens of equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to thrive and reach their potential.

• Serving as a role model confronting racist, sexist, or other inappropriate actions by speaking up, challenging exclusionary organizational practices, and standing side-by-side in support of colleagues who experience discrimination.

• Inspiring and fostering an environment of anti-racist behaviors among and between departments and co-workers.

At Mount Sinai, our leaders strive to learn, empower others, and embrace change to further advance equity and improve the well-being of staff, patients, and the organization. We expect our leaders to embrace anti-racism, create a collaborative and respectful environment, and constructively disrupt the status quo to improve the system and enhance care for our patients. We work hard to create an inclusive, welcoming and nurturing work environment where all feel they are valued, belong and are able to advance professionally.

Explore more about this opportunity and how you can help us write a new chapter in our history!

“About the Mount Sinai Health System:

Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 43,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time — discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients’ medical and emotional needs at the center of all treatment. The Health System includes approximately 7,400 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics and top 20 in Cardiology/Heart Surgery, Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report’s “Best Children’s Hospitals” ranks Mount Sinai Kravis Children's Hospital among the country’s best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 14 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek’s “The World’s Best Smart Hospitals” ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally.

The Mount Sinai Health System is an equal opportunity employer. We comply with applicable Federal civil rights laws and does not discriminate, exclude, or treat people differently on the basis of race, color, national origin, age, religion, disability, sex, sexual orientation, gender identity, or gender expression. We are passionately committed to addressing racism and its effects on our faculty, staff, students, trainees, patients, visitors, and the communities we serve. Our goal is for Mount Sinai to become an anti-racist health care and learning institution that intentionally addresses structural racism.”

EOE Minorities/Women/Disabled/Veterans

Requisition ID : 3012972