Medical Mgmt Clinical Coord-CMO

City/State

Yonkers, New York

Grant Funded

No

Department

NCM - Care Management 4A

Bargaining Unit

NYSNA

Work Shift

Day

Work Days

MON-FRI

Scheduled Hours

9 AM-5:30 PM

Scheduled Daily Hours

7.5 HOURS

Hourly Rate

$65.83

For positions that have only a rate listed, the displayed rate is the hiring rate but could be subject to change based on shift differential, experience, education or other relevant factors.

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Job Summary Working with IPA providers, other members of the interdisciplinary care team, and CMO Medical Directors and in accordance with regulatory and benefit coverage parameters, helps determine and coordinate comprehensive care plans 'appropriate to the health care needs of IPA members, including but not limited to, inpatient hospitalization, outpatient services, professional services, home care, durable medical equipment and other ancillary services. Evening and weekend hours may be required.

Essential Functions

• Reviews and evaluates authorization requests for inpatient, outpatient, specialty and out-of-network care and all other services requiring authorization within time frames and in accordance with criteria/guidelines specified by departmental policies and procedures. Completes 100% of assigned authorization reviews within the time frames required by regulation and specified by departmental policy and procedure or appropriately documents variances in any case not meeting timeframes. Applies appropriate criteria/guidelines in the review of authorization requests. Interprets criteria/guidelines accurately. Acts as a resource to UM Analysts ia adjudicating authorizations as per departmental policy and procedure.
• Identifies cages requiring case management and refers them to case management staff in accordance with depart mental guidelines. * Refers 100% of cases falling into those categories designated by departmental policy to appropriate case manager for evaluation.
• Using guidelines/criteria specified in departmental policies and procedures, identifies cases where services requested may not be medically necessary, requests pertinent clinical information and forwards available information to the Medical Director or Associate Medical Director for review. Reviews 100% of requests for service as well as ongoing care in accordance with appropriate criteria. Documents efforts to obtain additional clinical information in accordance with departmental policy And procedure in 100% of cases where this is required. Forwards identified cases involving issues of medical necessity to the Medical Director or Associate Medical Director for review. Monitors Response time frames and or escalates to management all variances
• Facilitates the discharge planning process for hospitalized members. Documents anticipated discharge plan at the time of the initial inpatient review. Evaluates post discharge needs involving interdisciplinary professionals through daily rounds, team conferences and written communication. Provides information as re: benefit coverage as needed, as well as available community services when appropriate. Ensures that the discharge plan is communicated to all disciplines in a expeditious manner and identifies and documents barriers to a timely discharge. Documents all variances resulting in potentially avoidable days in the UM system. * Provides timely documentation of discharge plan in 100% of cases to promote communication of plan between nurses performing case management and concurrent review functions
• Performs ongoing concurrent review of all assigned inpatient hospital admissions both in and out of network to determine appropriateness of admission and continued hospitalization. When appropriate discusses member's hospitalization with attending and as needed reaches out to the Primary Care Physician (PCP) to determine PCP's previous level of involvement, as well as any social or medical issues that need to be considered in the formulation of a discharge plan that will meet expected outcomes of members hospitalization. Conducts reviews in all cases where members are receiving extended services on a regular basis but at intervals of no greater than two weeks. Conducts ongoing review at regular intervals that do not exceed three days in all cases. Documents attempts to contact the Primary Care Physician, Informs manager of all cases where length of stay extends beyond five days, and all cases where there is any obstacle to obtaining information necessary to determine t