Resource Specialist

Purpose:
This person is responsible for coordinating both discharge services and facilitating utilization review through timely communication of clinical information to third party payers to ensure certification, approval and authorization of inpatient and post discharge services for patients. This individual collaborates with the outcomes management staff, physicians and patient care services regarding placement availability, discharge planning arrangements and insurance approval/denials for all inpatient and discharge services. This individual is responsible for independent retrieval, coordination and follow-up of applicable reports or worklists and oversight to promote proactive discharge planning, authorization of hospitalization, reimbursement at the appropriate level of care, decrease denials, and monitoring of activities to evaluate workflow to facilitate the department and system initiatives.

Responsibilities:

• Initiates and maintains accurate filing system Maintains appropriate office supply quotas and routine ordering when needed Copies and faxes materials as required. Ensures maintenance of equipment Performs other duties as assigned by the Director, Supervisor or Manager of the Department Provides support to the Hospitalist program by triaging incoming calls and assisting with the identification and implementation of processes within the program. Maintains appropriate, effective communications within and outside the department. Answers phone per PinnacleHealth policy, takes accurate messages, transfers calls appropriately Maintains confidentiality of clinical and personal information when talking with others, especially in public areas, in accordance with PinnacleHealth Hospitals Policy #15. Attends hospital required in-service programs. Supports department supervisor with duties as assigned.
• Maintains, updates, and disseminates post-acute care services information. Provides assistance to patients requesting a social services referral. Provides administrative support to the Director of Outcomes Management for assigned projects. Provides administrative support to Managers of Outcomes Management for assigned projects including confidential correspondence and special projects related to departmental functions. Responsible for correspondence and follow-up related to placement, third party payer authorizations and service coordination. Assures compliance with Department of Health, JCAHO, and other accreditation requirements and standards. Coordinates retrospective review for Medicare, Medicaid, third-party payers and other departments. Maintains information related to variance days. Provides physician-specific information to credentials office upon request. Assists in educating medical and professional staff in assessing performance, identifying risks, and action planning to improve performance.
• Initiates referral to post-acute service facility, documents in Soft Med. Communicates required information, identifies forms and requirements for all potential facilities, completes all forms appropriate for placement within time frame to prevent avoidable days, sends documents required to facility and documents appropriate information in department?s database. Continuously updates, provides prompt feedback regarding placement determinations to Outcomes Management staff, enabling them to evaluate/re-direct the current patient plan of care in order to streamline the delivery of service. Communicates all necessary information regarding placement and transportation to insurance companies and receiving facilities as needed. Completes arrangement and transfer process within requested timeframe. Obtain Durable Medical Equipment, transportation or other post-acute services as identified from the Outcomes Management staff.
• Works collaboratively with physicians, office staff, clinic and Outcomes Management personnel in order to facilitate accurate and timely authorizations. Conduct searches for post-acute care services and facilities and provides options for patients and families. Interprets/negotiates with individual payor, state, local, and federal agencies to optimize placement of patients in the most appropriate setting. Align needs of patients with placement options that are consistent with the desired quality and cost targets: such as, return to extended care facilities, assisted living, or reintegration into the home/community for patients. Identifies patients proactively requiring complex placement needs from Outcomes Management staff. Identifies post-acute services available for patient/family using the following criterion: Facility/service able to meet patient care needs
• Initiates the process for preparing cases designated by finance as Medical Assistance late pick-ups in order to receive authorization for payment. Requests and retrieves charts and chart copies from Health Information. Facilitates and coordinates activities for onsite reviewers and outside agencies. Develops and maintains a system for record keeping of resource utilization activities. Provides administrative support in the appeal process. This includes obtaining and communicating necessary information required to meet deadlines established by outside payers.
• Responsible for monitoring, reporting and communicating trends in insurance authorization, denial and appeal processes to the Resource Center Manager. Performs contract management analysis and makes recommendations regarding contractual modifications. Obtains payor certification and provider information for home care, Durable Medical Equipment (DME) and other post-acute services. Promptly enters and maintains certification information on appropriate information systems. Proactively communicates any change in payor information to Outcomes Management staff and documents changes appropriately. Identifies concurrent denials by third party payors and notifies Outcomes Management staff for immediate intervention. Ensures payor and customer satisfaction through effective communication and positive customer service skills at all times. Maintains, updates, and disseminates payor grid. Participates in performance improvement activities. Acts as a liaison to share patient-specific insurance and updates to pertinent areas. Negotiates concurrent denials and communicates findings to the Case Manager or Outcomes Manager. Verify with patient financial counseling that all payment sources have been explored, including charity.
• In cooperation with the Resource Center Manager, develops, reviews/revises and implements departmental policies, procedures and processes. Effectively communicates clinical information negotiates with payors and maintains relations with third party payers in collaboration with the Outcomes Management staff to obtain authorization for appropriate level of care and length of stay and documents interactions in information system Provides prompt feedback regarding payor determinations to Outcomes Management staff, enabling them to evaluate/re-direct the current patient plan of care in order to streamline the delivery of service. Investigates and resolves billing issues, delays in authorizations and denials proactively. Oversees the denial management process, concurrent payer authorization, and onsite insurance reviewers to ensure compliance with Pinnacle Health processes and contracts. Independently facilitates the appeal process in accordance with the Utilization Review Plan.