RN Coordinator (Surgery Screening) - Case Management - Full Time 8 Hour Days (Non-Exempt) (Non-Union)

The RN Surgery Screening Coordinator provides oversight of pre-admission evidence-based criteria evaluation of elective surgeries. This is accomplished through identification of patients scheduled for elective surgery prior to the surgery date, evaluation of established evidence-based criteria, adherence to established escalation processes, and collaboration with key stakeholders to better ensure appropriate and timely reimbursement of rendered services.

Essential Duties:

• Collaboration and communication with key stakeholders including: surgery schedulers, providers, hospital financial counselors, hospital utilization review staff and case managers, Physician Advisors, and payers.
• Collaboration with surgery schedulers and authorization coordinators to accurately identify patients scheduled for elective surgery prior to scheduled surgery date.
• Evaluation of established evidence-based criteria for hospital elective surgeries including, but not limited to: proposed admission status; authorization obtained by clinic staff; CMS Inpatient Only List; InterQual Inpatient Surgical List.
• Inclusion of hierarchy of evidence-based criteria to establish appropriate surgical status for correct billing of planned surgical procedure(s): CMS Inpatient Only List and other CMS regulatory guidelines versus InterQual Inpatient List versus payer-specific criteria.
• Implementation of escalation processes, including communication with provider and consultation with Physician Advisor when criteria are not met and/or proposed admission status is incorrect, and the physician does not agree with RN Surgery Screening Coordinator determination.
• Facilitation of scheduling of Peer-to-Peer meetings when payer denial received.
• Documentation of evaluations, including escalations and outcomes, in the Electronic Medical Record (EMR) in a timely manner and viewable by key stakeholders such as Case Managers, Physician Advisors, Patient Access, and Claims.
• Post-surgical validation of surgery performed and status ordered to confirm they are in accordance with established CMS and hospital guidelines.
• Post-surgical evaluation of the operative note to confirm the procedure(s) performed conforms to the payer authorization received. When a mismatch in procedure(s) performed is identified, works with the provider and the payer to obtain appropriate updated payer authorization.
• Collection of pre-operative and post-operative data components for reporting, tracking, and trending of identified quality improvement opportunities in department processes, provider practices, and payer determinations.
• Participation in department Inter-Rater Reliability process.
• Maintain competencies for hospital, age specific and job specific standards of care, follows hospital procedures for accurate and timely processing of charges.
• Documentation of avoidable delays in the EMR.
• Represents the department in a positive and professional manner.
• Supports orientation of new staff.
• Supports hospital and departmental protocols, workflows, policies, procedures, standards, and competencies for clinical role.
• Supports the mission, vision, and values of the organization.
• Performs other duties as requested/assigned.

Required Qualifications:

• Req Bachelor's Degree Nursing Degree from an accredited school of nursing

• Req 3 years Clinical experience as a Registered Nurse
• Req 2 years Utilization Review and Case Management experience in an acute hospital setting
• Req Experience with InterQual evidence-based criteria

• Req Demonstrates ability to utilize effective and appropriate oral and written communication skills.
• Req Demonstrates ability to effectively work with physicians, staff, patients, and payers.
• Req Commitment to excellence in patient care and customer service.

Preferred Qualifications:

• Pref Certified Case Manager - CCM (CMSA) Nationally recognized certification such as CCM and/or ACM

Required Licenses/Certifications:

• Req Registered Nurse - RN (CA Board of Registered Nursing)
• Req Basic Life Support (BLS) Healthcare Provider from American Heart Association
• Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)