Duke Connected Care, a community-based, physician-led network, includes a group of doctors, hospitals and other healthcare providers who work together to deliver high-quality care to Medicare Fee-for-Service patients in Durham and itssurrounding areas.
Perform a variety of specialized, complex activities in the coordi nation of the care needed for patient discharges and transitions of care . Strong emphasis on proactive problem resolution and departmental commu nications.
Independently perform activities necessary to organize, maintain, and use electronic patient health records. Positions at this level have high customer service, strong analytic and problem solving sk ills, require interpretation and explanation of policyand external requirements related to, privacy, release of information, positive patient id entity, and other department and organization-wide functions.
Regu lar interaction required with case management staff, physician advisors, post-acute care providers, community based organizations, insurance com panies, and governmental agencies.
Detailed working knowledge and ability to apply HIPAA rules, North Carolina General Statutes, and other State and Federal laws regarding patient privacy. Detailed working know ledge and ability to apply State and Federal laws regarding discharge pl anning, Joint Commission requirements, and CMS guidelines and rules.
Duties and Responsibilities of this Level
Partn ers with Case Management team in arranging for discharge needs of patien tsincluding but not limited to durable medical equipment, home health, f acility placement, dialysis, outpatient appointments, back transfers to outside hospitals, transportation, and home infusion.
Performs a v ariety of specialized, complex activities in the coordination of post-ac ute care services. Reviews discharge planning forms for completeness, ti ming, and conformity to policy and guidelines. Delivers the Important Me ssage from Medicare according to CMS guidelines to all indicated patient sbased on case manager's noted expected discharge date.
Participat es in daily Case Management touchpoints with Case Managers, Social Worke rs, and Utilization Managers. Discusses referred cases, including, patie nt status, barriers to discharge, payer communication, expected discharg e date, transition planning priorities, escalations and support needed.< /p>
Reviews insurance coverage updates on all appropriate patients, as assigned. Regularly evaluates work list and re-prioritizes items for the day. Reviews requests for care coordination to identify dates of servic e, entity, provider and specific clinical documents needed to completeth e requested referrals. Works extensively in the electronic health record to locate specific clinical documents for the purpose of fulfilling are quest. Escalates more complex inquiries and barriers to the appropriate resource.
Stays in close contact with the requester to alert Case Management Staff of barriers to completion of needed task, provide statu s updates and ultimately share details of case completion. Enters approp riate documentation of all discharge planning activities and communicati ons according to department standard and closely monitors pending tasks andpriority level of each task.
Maintains strong working relation ships with both internal Duke staff as well as external agency staffsuch as post-acute liaisons, admissions coordinators, medical providersand s taff in community-based organizations toensure timely, appropriateand s afe transitions of care.
Obtains all authorizations for SNFcare, b oth by utilizing the NaviHealth portal for the payers who utilizethat sy stem as well as any other processes used by all other managed care and h ealth plans. They will also use a similar system as NaviHealth utilized by the State to approve all post-acute care (including Home Health) for Medicaid beneficiaries covered by these commercial plans.
Schedule s peer-to-peer reviews for Physician Advisors (PAs) and communicate elec tronically to the PAs the dates/times and contact names/numbersof the pa yer's Medical Director with whom they will be speaking. Discusses ration ale for initial denial of services with the PAs to assist in their prepa ration for the peer to peer discussion. Meticulous record keeping of thi s process will be expected as data will be needed to assess volume for f uture expansion.
Develops, administers activities, monitors and ev aluates program effectiveness, and investigates trends. Advisessuperviso r as to the status of current activities and additional or expanded prog ram requirements. Provides input into appropriate program recommendation s or conclusions. Assists in developing and defining short andlong term departmental specific goals and objectives. Implements decided upon prog ram adjustments. Coordinates projects and audits to improve processes re lated to Case Management efficiency of care coordination anddischargepla nning.
Requires the ability to interpret and explainpolicy and ext ernal requirements related to, discharge planning, releaseof information , positive patient identity, and other department and organization-wide functions. Completes regular interaction, as indicated, with governmenta l agencies, providers of health care, insurance companiesand auditing ag encies. Possesses a detailed working knowledge and ability to apply HIPP A rules and other State and Federal laws regarding patient privacy. Poss esses working knowledge of Joint Commission requirementsand CMS guidelin es and rules.
Develops, coordinates and advises staff regarding re levant policies and guidelines. Educates and trains employees in proper methods and procedures to ensure efficient and accuratecompletion of wor k. Develops and provides job-specific training to newand existing employ ees within department.
Required Qualifications at this Lev el
Education
Associate's degreein business, health care administration, social work or a related healthcare.
Bachelor 's degree in business, healthcare administration, social work or a relat ed healthcare field highly preferred.
Experience
2 years of related experience required
ABachelor's degree in a related field can substitute for the experience requirement.
Degrees, Licensure, and/or Certification
N/A
Knowledge, Skills, and Abilities
Good organizational skills, excellent investigative/analyticskills with detail orientation , and strong follow-through capabilities.
Excellent verbal and wri tten communication skills in order to effectively problem solve, develop working relationships and assist case managers, utilization managers an d social workers.
Must be able to meet deadlines, work independent ly, set priorities and maintain confidentiality.
Ability to work c almly and efficiently in high-pressure situations
Strong computer skills including word processing, spreadsheet development and completion and fluent in the use of electronic medical record.
Must possess excellent written and verbal communication skills,and be skilled in team building and negotiation.
Skilled in data analysis and applicatio n of data to operational processes.
Minimum Qualifications
Education
Associate's degree in business, healthcare administration, social work or a related healthcare. Bachelor's degree in business, healthcare administration, social work or a related healthcare field highly preferred.
Experience
2 years of related experience required A Bachelor's degree in a related field can substitute for the experience requirement.
Degrees, Licensures, Certifications
N/A
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Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.