RN Case Mgr/Doc Specialist - Orlando Health

Promotes and facilitates effective use of outpatient hospital and clinic resources.

Essential Functions
• Assists with developing comprehensive case management plan addressing patient/family needs.
• Audits documentation and denied claims, ensures compliance with documentation requirements, and assists in resolving
medical necessity pre- and post-payment issues.
• Interacts with patients and family members, physicians, nurses, and other physician office staff, business office, pharmacy,
insurance companies, and other departments to facilitate delivery of quality patient care ensuring medical necessity criteria are
met.
• Audits accounts when preauthorization has been denied for outpatient services and determines process for appeal, etc.
Facilitates physician-to-physician case reviews as needed.
• Collaborates with representatives from PFS/appeals department to appropriately facilitate all appeals with Administrative Law
Judge.
• Conducts audits of orders written to ensure medical necessity criteria are met. Reviews claim denials and collaborates with
physicians to establish medical necessity. Reviews denials of off label treatments in compliance with review requirements for
Managed Care contracts, governmental payers (i.e. Medicare, Medicaid, and Champus), and departmental review policies.
Collaborates with physicians regarding medical necessity criteria and determination of pursuit of appeal.
• Develops collaborative relationships with patients/families, patient business, nursing staff/leadership, physicians, social
workers, and ancillary services to facilitate optimum outcomes of outpatient case management activities.
• Collaborates with coding, PFS, revenue integrity and appeals departments to ensure medical necessity criteria are met for
billable charges. Conducts medical review of charges for coding and billing accuracy and medical appropriateness in support of
payment policies of organization and individual payers.
• Conducts audit of pre-billed claims within database for medical necessity and provides additional required information to
support billable charge. Identifies inappropriate charges and works with billing/revenue integrity departments to identify root
cause. Works closely with charge analysts as a medical resource.
• Performs retroactive medical records review to determine medical necessity of services.
• Identifies trends within the outpatient departments and provides staff education for performance improvement.
• Participates in outpatient staff meetings, revenue committee meetings, case management staff meetings, and task force
working to facilitate Sunrise into the outpatient practice areas. Offers cost-containment suggestions and provides feedback as
needed.
• Provides ongoing education to physicians and staff as well as referring off campus physicians regarding medical necessity
criteria and reimbursement guidelines.
• Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA, and other federal,
state, and local standards.
• Maintains compliance with all Orlando Health policies and procedures.

Education/Training
• For Team Members hired into this job prior to January 1, 2020:
o Completion of an accredited RN education/training program
o Bachelor’s degree
• Effective January 1, 2020: New Hires and Team Members moved into this job and/or transferring Depts. must obtain a
Bachelor of Science in Nursing degree (BSN) within 36 months of placement.
Licensure/Certification
Maintain current RN license in the state of Florida.
Experience
• Five (5) years’ acute care experience, OR
• Five (5) years’ experience in case management, hospital discharge planning, risk management, quality assurance, and/or
utilization review