Behavioral Health RN Care Coordinator

Heywood Hospital•Gardner, MA

5d•Onsite

About The Position

Heywood Healthcare values its employees and offers competitive wages, great benefits, and generous earned time off. This Per Diem, day shift position does not require weekend or holiday work. The role involves utilization management, including utilization review and care transitions & coordination. The Behavioral Health RN Care Coordinator will provide clinical information to payers, monitor length of stay, seek necessary care authorizations, and appeal denials in a timely fashion. They will also track and trend opportunities for improvement related to insurance reviews and length of stay. The position requires daily completion of concurrent and retro utilization reviews for psychiatric appropriateness according to approved criteria. The RN will demonstrate clinical expertise in issuing ABN/HINN notices and managing the Medicare Important Message appeal process, keeping the physician and team informed of status changes and documenting them. Collaboration with the BH Clinical Team is essential for educating patients, families, and care providers on continuing care, care management, length of stay, re-hospitalization, and disease management. The role also involves participation in multidisciplinary team rounds for discharge planning, working collaboratively to determine patient needs, addressing length of stay issues, and identifying resources. Quality and statistical data review, including medical records for abnormal findings and deviations from expected outcomes, is also a key responsibility. Maintaining current knowledge of regulatory requirements and insurance review procedures, redesigning systems for performance improvement, and assisting with reports and statistics are expected. The RN will review pre-admission screen forms for accuracy, note pre-authorized dates of service, and ensure reimbursement by correcting issues with pre-authorization, including obtaining auth for patients admitted without proper authorization. Daily comprehensive utilization reviews for inpatient psychiatric and substance use disorders are required to ensure compliance with medically necessary criteria. Requesting administratively necessary days and determining state involvement for DMH active clients are also part of the role. Participation in 72-hour meetings with patients, families, and the healthcare team to facilitate education on anticipated length of stay and advance discharge planning is required. Attending collaborative meetings with insurers to review statistical trends, discuss complex cases, and review quality data reports is also a responsibility. The role includes managing the denials/appeal process, assessing denials, providing supporting documentation, and coordinating Medical Director and Peer to Peer reviews. Preparing written appeal letters, termination letters, discharge notices, MOON, and IMs as per regulatory standards and department policies is necessary. Reporting variances and trends to the director and collaborating with the Director of Behavioral Health to address patient accounts with payment denials are also key functions. Communication with physicians, managed care plan reviewers, healthcare team members, third-party payers, outside reviewers, and vendors is crucial for enhancing customer service satisfaction. The RN will collaborate with the BH Social Worker throughout patient admission to provide assistance and guidance for discharge planning needs. Maintaining familiarity with inpatient behavioral health social work functions, including discharge planning, care coordination, community referrals, family communication, resource identification, and documentation requirements, is necessary to ensure continuity of care during Social Worker absences or increased unit needs. Other duties as assigned by the director or designee are also part of the role.

Requirements

BSN preferred.
RN with current Massachusetts Registered Nurse License required.
Previous UR/QA experience required.
2 years of healthcare experience within Behavioral Health and/or Insurance Industry required.
Discharge Planning experience as it pertains to the care transitions, referral process, patient preference/choice; services, patient & family satisfaction; post discharge follow up etc.
Proficient computer skills required.
Must have effective written, verbal and interpersonal communication skills.
Excellent critical thinking.
Ability to multitask and flexibility essential.

Responsibilities

Providing clinical information to payers, monitoring length of stay, seeking necessary care authorizations and appealing denials as indicated within a timely fashion.
Follows-up on lack of documentation for medical necessity, supporting documentation with discipline identified.
Track and trend opportunities for improvement resulting in late Insurance Reviews, longer lengths of stay
Completes utilization reviews daily and/or as required by insurer, (concurrent and retro) for psychiatric appropriateness according to Hospital's approved criteria timely and efficiently.
Demonstrates clinical expertise specific to the issuance of ABN/HINN notice to patients and/or legal significant other and care progression.
Responsible for insurance interactions related to Medicare Important Message appeal process.
Keeping physician and team informed of status change and documenting status.
In collaboration with the BH Clinical Team provides education and information to patient, family and care providers as it pertains to continuing care, care management, LOS, re-hospitalization and assure understanding of disease management.
Participates in discharge planning teams daily.
Works collaboratively with multidisciplinary team to determine each patient's needs concurrently including post-acute care when needed; addresses LOS issues, appropriate leveling of patient status; addresses, potential needs, resources, referrals for other disciplines etc.
Reviews medical record for abnormal findings, complications, delays and deviations from expected clinical outcomes reports such to Provider and/or Director to maintain an efficient, cost effective episode of care for each patient and documents intervention provided.
Maintains current working knowledge regarding regulatory requirements and insurance review procedures, forms, and portal updates.
Utilizes knowledge to redesign systems for improving performance.
Continuously prioritizes projects, activities, and tasks to ensure deadlines and customer needs are met.
Assists with preparation of reports/statistics as it pertains to staff specific workflow.
Reviews pre-admission screen forms for accuracy.
Note any pre-authorized dates of service and insurance specific communication related to concurrent review/discharge notification.
Responsible for correcting issues with pre-auth to ensure reimbursement – including obtaining auth for patients who are admitted without proper auth in place.
Conduct daily comprehensive utilization reviews for inpatient psychiatric and substance use disorders to ensure compliance with medically necessary criteria.
Request administratively necessary days when a patient no longer meets criteria for inpatient level of care.
Determine state involvement as reimbursement for DMH active clients differs from the standard Medicaid rate.
Participate in 72 hour meeting with patient/HCP/Family/Guardian,Social Worker, and Unit Leader to facilitate education regarding anticipated LOS and advance discharge planning inititation/expectations.
Attend collaborative meetings with insurers to review statistical trends, discuss complex cases, and review quality data reports
Completes assessment of denial within 1 week providing supporting documentation with outcome of review; documents intervention in the UR EMR section.
Coordinates Medical Director and Peer to Peer reviews in accordance with insurance regulations.
Prepare written appeal letters, termination letters, discharge notices, MOON and IMs when appropriate as per regulatory standards and department policies.
Report any variances, trends to director.
Submits denials/appeals when completed.
Collaborate with Director of Behavioral Health to address BH patient accounts where payment denial exists – work with denial mgmt team for resolution.
In collaboration with BH Social Worker builds rapport and responds to needs of physician, reviewers for managed care plans, healthcare team members, 3rd party payers, outside reviewers and vendors to enhance internal and external customer service satisfaction.
Throughout patient admission collaborates with the BH Social Worker to provide assistance and guidance ongoing for discharge planning needs.
Maintain sufficient familiarity with inpatient behavioral health social work functions, including discharge planning, care coordination, community referrals, family/collateral communication, resource identification, and documentation requirements, to ensure continuity of patient care during periods of Social Worker absence or increased unit need.
Performs any and all other duties as assigned by director and/or designee.