Clinical Liaison

Tenet Healthcare•Detroit, MI

About The Position

The Clinical Liaison acts, under limited direction and according to established policies and procedures, as a member of the care management team. The role applies medical necessity criteria to determine the appropriate level of care at patient access points, which may include acute care hospitals, post-acute venues, clinics, or patients’ homes. The Clinical Liaison integrates third-party payer-specific agreement criteria and interfaces with payer representatives. The position is responsible for pre-admission assessment of patients referred for inpatient acute services and recommends alternate levels of care when a patient is not an appropriate admission candidate. It coordinates collection of relevant patient information from medical records, onsite and telephonic interviews, and electronic sources to pursue insurance authorization and verify admission criteria. The role communicates admission decisions promptly to referral sources and consults with interdisciplinary team members as needed. The Clinical Liaison communicates with patients, families, medical teams, caregivers, and third-party payers; analyzes case management outcome data to support appeals and denials; participates in utilization review and quality improvement activities; and maintains current knowledge of healthcare practices, payer requirements, and admission criteria. The position also builds effective relationships with physicians, staff, and referral sources, identifies and resolves customer concerns, and promotes positive customer relations. Other duties and functions may be assigned.

Requirements

Graduate from an accredited school of nursing.
Bachelor’s degree in Nursing or another health-related field, or an equivalent combination of education and/or related experience.
Three to five years of clinical or nursing experience.
License to practice as a Registered Nurse in the State of Michigan, or license to practice as a Physical Therapist, Occupational Therapist, or Speech Language Pathologist in the State of Michigan.
Analytical ability and comprehensive knowledge to identify improvement opportunities, resolve problems, evaluate patient status and healthcare procedures, and monitor quality of patient care.
Fiscal skills to monitor and control costs and revenue, with working knowledge of the revenue cycle and the impact of utilization management decisions.
Interpersonal skills to work productively with all levels of hospital personnel.
Verbal and written communication skills to communicate effectively with diverse populations, including physicians, employees, patients, and families.
Proficiency in applying standard appropriateness criteria sets, such as InterQual.
Flexibility with scheduling, including off-shifts, weekends, and holidays, to meet the needs of patients, families, or staff.
Leadership skills to direct others toward objectives that contribute to department success.
Ability to cope with stressful situations and manage multiple, sometimes conflicting, priorities simultaneously.
Ability to integrate third-party contractual arrangements into the pre-admission review process.

Nice To Haves

Previous related experience with the targeted patient population.

Responsibilities

Apply medical necessity criteria to determine the appropriate level of care at patient access points.
Integrate third-party payer-specific agreement criteria and interface with payer representatives.
Communicate with patients, families, medical teams, caregivers, referral sources, and third-party payers as needed.
Analyze case management outcome data to facilitate appeals and address denials.
Maintain current knowledge of healthcare techniques and practices through educational programs.
Participate in the Utilization Review committee process as needed.
Maintain working knowledge of payer requirements and admission criteria for the patient population.
Conduct pre-admission assessments for patients referred for inpatient acute services.
Recommend alternate levels of care when a patient is not an appropriate candidate for admission.
Coordinate collection of relevant patient information from medical records, onsite and telephonic interviews, and electronic sources for insurance authorization and admission criteria review.
Communicate admission decisions quickly and effectively to referral sources.
Consult with interdisciplinary team members regarding potential admissions as necessary.
Participate in quality improvement activities as directed or necessary.
Establish and maintain effective relationships with physicians and other internal and external staff.
Identify and resolve problems or dissatisfaction reported by customers or referral sources.
Use concern, poise, understanding, honesty, and tact to turn negative situations into supportive relationships.
Promote a positive customer relations environment.
Perform other duties and functions as assigned.