EvergreenHealth Monroe, a small semi-rural acute care hospital. Working together, we exist to serve the changing health care needs of our community. We will provide personalized patient care known for quality and excellence with a healing environment through caring relationships.Come join our dynamic team and learn all that EvergreenHealth Monroe has to offer!

Wage Range: $48.91 - $78.25per hour.The amounts listed are the base pay range; additional compensation, such asshift differentials and premiums may be available for this role. Job offers are determined based on a candidate's years of relevant experience, applicableeducation and internal equity.

Benefit Information:
Choices that care for you and your family

At EvergreenHealth Monroe, we appreciate our employees’ commitment and contribution to our success. We are proud to offer a suite of quality benefits and resources that are comprehensive, flexible, and competitive to help our staff and their loved ones maintain and improve health and financial well-being.

• Paid Sick Leave
• Employee Assistance Program
• Cafeteria Discounts
• Free parking

OUR MISSION:
EvergreenHealth will advance the health of the community it serves through our dedication to high-quality, safe, compassionate, and cost-effective health care.

OUR VISION:
EvergreenHealth will create an inclusive community health system that is the most trusted source for health care solutions

OUR VALUES:
Compassion - We care for and about our patients, families, and each other
Respect - We respect the beliefs and values of everyone we encounter
Excellence - We strive for excellence in all we do
Collaboration - We work in partnership and believe every voice makes a difference
Accountability - We are accountable to one another and to our community

JOB SUMMARY :

Adheres to Hospital’s Policies and Procedures and Philosophy of Care. Consistently exhibits professional conduct that is a behavior-based expression of the hospital’s Standards of Excellence. Responsible for evaluating, providing justification and documenting admission, treatment and length of stay for patients using InterQual criteria. Provides clinical review to payers to meet agency requirements. Has knowledge of and participates in the appeals process. Functions as a member of the multi-disciplinary team to screen and assess patients for post-hospitalization needs, and to determination appropriate discharge assistance. Works with patient and family members to evaluate patient care needs to assure most appropriate discharge plan, and ensure understanding and compliance with discharge plan. Provides resources, counseling and information to patients and families in the Emergency Department. Works with patients and families in monitoring and adhering to disease management programs. Completes work adhering to HIPAA, EMTALA, DPOA, CMS requirements and other governing agencies laws and structures that oversee patient rights. Regular on-site attendance is required.

REQUIRED EDUCATION, TRAINING, EXPERIENCE AND CERTIFICATION/LICENSURE:

A minimum of 2 years experience in an acute care setting is required. A background in nursing, social services, hospital health unit coordinator or other related experience is preferred. Experience with Utilization Review and Discharge Planning in an acute care setting is preferred.

SPECIAL EQUIPMENT, SKILLS OR OTHER REQUIREMENTS:

Excellent written and verbal communication skills, and interpersonal skills. Requires effective communication skills with all age groups and/or cultures, as well as with other health care team members. Must have excellent organizational skills, computer skills, and general office skills. Must be self motivated, cooperative, versatile and flexible. Must assess, evaluate and format information for hospital wide use. Must adapt to changing schedules, policies and workload. Must prioritize tasks and provide assistance to others. Bi-lingual preferred.

WORK ENVIRONMENT AND HAZARDS:

Adheres to all State and Federal regulations pertaining to hazardous materials. Risk of exposure to communicable diseases.

WORK CONTACT GROUP:

All departments, physicians, insurance contacts and patients.

SPECIAL PHYSICAL DEMANDS:

Spends significant time on telephones; charting and consultation/coordination. Spends significant time using the computer and keyboard and monitor.

SUPERVISED BY:

Manager, UR/Care Transitions

ESSENTIALFUNCTIONS:

• Concurrently monitors patients to assure the appropriateness of admission, continued hospitalization, length of stay, utilization of resources and any potential denial of payment issues.
• Evaluates documentation regarding severity of illness and intensity of service for variation from regulatory agency standards.
• Consults with physicians as necessary to resolve deviations.
• Obtains correct physician order for change of status when appropriate.
• Documents patients need for continued hospitalization.
• Reviews and records reviews for all patients who transfer to a higher level of care within the hospital.
• Performs retrospective reviews applying appropriate clinical and medical necessity guidelines (as defined by InterQual) to respond to post billing payer requests for information and/or to appropriately appeal to payer denials of payment.
• Completes insurance appeals for denied services and/or claims and participates in the RAC and appeals processes.
• Provides patient notices of payer continued stay denials in accordance with requirements within EvergreenHealth Monroe payer contracts.
• Enters pertinent authorizations, approved LOS, payer communication into the patient account notes in the hospital HIS application and other repositories and computer systems as directed.
• Provides information to physicians regarding opportunity/need for additional documentation to support patient severity of illness and intensity of service to more accurately reflect the medical condition on the record (reflecting appropriate complications or co-morbid conditions).
• Screens and assesses all inpatient and observation patients to determine potential discharge needs.
• Defines and maintains discharge plans for all inpatients and observation patients, and records plan with changes and outcome.
• Pre screens and set up potential discharge plan for scheduled total hip and total knee replacement patients. Alters and updates as required.
• Meets with patients and families to determine/ explain patient discharge placement options and needs. Able to respectfully determine the best solutions for patient placement based on the patient’s residential location, family needs and financial resources.
• Assists patient and families with information about local resources and choices for post hospital placement and services.
• Makes arrangements with outpatient facilities and providers for follow-up care post discharge, as needed.
• Demonstrates a clear knowledge of all community resources and services available to patients in the community.
• Creates a good network of connections by visiting and establishing a good working relationship with employees of local Skilled Nursing facilities, Adult Family Homes, or other facilities on behalf of EvergreenHealth Monroe. Represents EvergreenHealth Monroe in a professional manner.
• Maintains files on all resources and ensures information availability to patients.
• Ability to assist patient and their families with application for DSHS coverage for nursing home room and board.
• Presents initial Important Message from Medicare plus mandated follow-up message prior to patient discharge as required, to both Medicare and Medicare Advantage plan patients.
• Ensures follow-up of patients Advance Directive choices. Inquires about the choice to make an Advance Directive and Living Will, and if requested, provides information and assistance to complete the documents.
• Communicates effectively with staff including physicians, nurses, HUCs, and other providers to discuss patient care needs and plan for timely discharge to the appropriate setting.
• Demonstrates ability to work independently, organizing and prioritizing tasks to be completed and completing all job responsibilities in a timely manner. Must be flexible with schedule to the extent willing to stay late when needed or to leave early when job requirements are low.
• Participates in departmental meetings and activities related to developing, reviewing and revising policies, procedures and processes.
• Participates in external education related to case management, utilization review, discharge planning and other related industry trends.
• Maintains an ongoing knowledge of federal, state and local rules and related to hospital acute care coverage, SNF and home care services and reimbursement. Serves as a resource to physicians and families regarding reimbursement and cost of services.
• Maintains responsibilities and performs assigned duties as part of the patient advocate for the disease management program. Participates in evaluation and improvement of the program throughout its duration.
• Assess and coordinates options for Emergency Department patients with regard to discharge, placement, resources, DME options, and other care management needs as they arise in the department.
• Acts as a patient advocate, especially related to insurance coverage and post discharge needs. Makes referral to social work services staff to assist with any behavioral or drug/alcohol dependence issues, especially relating to patient and/or family safety concerns.
• In coordination with the attending physician and the hospital’s interdisciplinary care team, participates in the assessment of the patient’s post discharge needs based on medical status, physical mobility and function, development of psychological needs, family and community support and financial resources.
• Completes all other jobs, projects and tasks as requested