Perform daily or as clinically indicated telephonic or on-site clinical reviews for patients in the acute hospital setting and in accordance to DNV, CMS, DMHC and managed care requirements via published workflow and productivity standards
Evaluate and monitor patients for inappropriate admissions, appropriate level of care and length of stay Apply MCG, goal length of stay or other applicable evidence based guidelines (i.e.: Milliman, MCG). Assist in maintaining hospital bed days within goals set by MCMF UM/CM program
Document readmission, issue variances or denials when applicable.
Work collaboratively with hospital departments including; Hospitalists, Specialty Providers, charge and staff nurses, behavioral health and other identified hospital based services
Provide Hospital staff with contracted providers per health plan contracts
If on site meet with patient and/or family at bedside based on standard workflow or telephonically if remote position
Evaluate, ensure and evaluate the execution of each patient’s discharge plan and instructions to ensure safe care transitions and all follow up needs are ordered and in placed based on benefits and eligibility
Determine patient level of acuity and refer to Discharge Clinic, Complex Case Management and Disease Management as indicated
Participate in inpatient rounds, huddles, team meetings webinars, training and any other meetings as directed by leadership team.
Repatriate patients whenever possible if admitted to out of network facilities. Assist health plan repatriate out-of-area patients by providing Hospital Bed Board and Hospitalist phone numbers. Ensure that patients are followed by assigned/contracted Hospitalist and contracted Specialists
Submit letter of agreement for non-contracted physicians to contracting department when indicated
Understand DOFR’s (division of financial responsibility) as it relates to the inpatient process