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Care Manager, Senior

Company: Orlando Health
Location: Saint Petersburg
Posted on: January 13, 2022

Job Description:

Care Manager, Senior - Bayfront Health St. Petersburg Case Management - Day

Department: Case Management

Status: Full Time

Shift: First

ReqID: req30235


701 6th Street South,

St. Petersburg, Florida, 33701,

United States

Bayfront Health St. Petersburg

Situated in the heart of downtown St. Petersburg on Florida's Gulf coast, Bayfront Health St. Petersburg has served the residents of the region for more than 100 years and joined the Orlando Health system in 2020. Bayfront Health St. Petersburg is a 480-bed tertiary care center equipped to provide comprehensive medical and surgical care. The hospital offers many areas of expertise, including surgery and trauma, neuroscience, cardiology, acute rehabilitation and obstetrics. The hospital has a 38-bed neurosciences unit with a dedicated neurology team consisting of board-certified neuroscience specialists and physicians with subspecialty expertise in stroke, epilepsy and Parkinson's disease, and includes a Level IV Epilepsy Center. In partnership with Johns Hopkins All Children's Hospital, Bayfront Health St. Petersburg Baby Place offers full obstetrical services and is a Level III Regional Perinatal Intensive Care Center, one of only 12 in Florida. The hospital also is home to the Bayfront Health St. Petersburg Cardiac Cath Lab, located in the James Heart Center, which offers a full range of cardiovascular care and an on-site inpatient rehabilitation unit, as well as the nearby Bayfront Health St. Petersburg Wound Care & Hyperbaric Center.

Position Summary

Responsible for ensuring an efficient, cost effective care management process by determining the patient's medical necessity and financial liability through the coordination of insurance reviews and issuance of authorization numbers through submission of

required clinical information.


Bachelor's degree in a healthcare related field.


Maintains current license as a Registered Nurse (RN) in Florida.

Certification as an InterQual trainer within six (6) months from date of hire.


Five (5) years of acute clinical experience to include at least two (2) years in utilization management.

Essential Functions

  • Guides the care managers in the performance of medical record reviews for medical necessity of admission and the placement of the patient in appropriate bed status.
  • Works directly with the Care Management department, the Business Office, Patient Access, and along with the Hospital's Revenue

    Cycle to ensure quality and efficiency of certain elements of claims processing, denial prevention, and denial management.

    • Retrieves designated reports from Allscripts Care Management and other systems in an effort to identify, organize, prioritize, and validate the requests for pre-authorizations and/or authorizations have been obtained or that appropriate, timely follow-up has been completed.
    • Responds to internal and external inquires in person, through telephone calls, or electronically, routing calls to appropriate individuals.
    • Retrieves and disseminates face sheets, consultation requests, clinical, and other information, as deemed necessary, to appropriate individual(s) in a timely manner.
    • Submits/faxes required/ requested clinical information to insurance company for authorization of patient hospitalization.
    • Coordinates insurance company requests and authorization numbers with the care managers and Patient Access Department.
    • Enters authorization numbers and appropriate payer documentation/correspondence into the Allscripts system.
    • Completes retrospective reviews utilizing the daily discharge list to validate that all patients had an initial medical necessity review completed and the outcome is favorable for reimbursement of the designated bed status. If an initial admission medical necessity was not completed, the Care Manager, Senior will assign the review to be completed by a unit Care Manager, or will complete

      the review. Note: These retrospective reviews are time sensitive, due to the coding and billing guidelines and need to be completed within 3 days of the patient's discharge. Any discrepancy needs to reconciled immediately and/or notification of the appropriate HIM or Business Office Staff to "pend" the account.

      • Completes retrospective medical necessity review for all readmitted patients within 30 days to identify if there is any quality of care and/or premature discharge. If a quality of care issue is identified and the patient's readmission may be directly related to the a failure of the treatment or discharge, discuss findings with the Physician Advisor and coordinate the processing and billing of these two admissions as one DRG. If no quality of care or failure of treatment or discharge plan is identified, coordinate with the business to prepare each account for a separate DRG payment.
      • Assist in appealing existing denials by communicating necessary information to the payers.
      • Assists in denial prevention by proactively communicating with care management staff, the bedside nurses, physicians and the Physician Advisorin obtaining pertinent information. Also actively assists with the request by the payer(s) for Peer-to Peer reviews.
      • Demonstrates the knowledge and skills necessary to provide appropriate care in consideration of the growth development, and social needs of pediatric, adolescent, adult, and geriatric patients.
      • Enhances professional growth and development through participation in educational programs, current literature, in-services, meetings, and workshops.
      • Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards.
      • Maintains compliance with all Orlando Health policies and procedures.

        Other Related Functions

        • Assists Business Office personnel in preparing appropriate documentation relating to the admission, denials and appeals process.
        • Communicates with the payer(s) to facilitate covered-day reimbursement authorization for assigned patients. Discusses payer criteria and issues on a case-by-case basis with pertinent clinical staff and follow-ups timely to resolve issues with payers to avoid denials or reimbursement penalties as well as any medical necessity determinations which may result in patient liability.
        • Escalates cases to the Physician Advisor when the patient is not satisfying criteria and/or a quality of care concern is identified. Assists Care Manager to identify patient with barriers to discharge as well as patient with a high risk of readmission and communicate to payer and Care Management Team.
        • Discusses High Risk Length of Stay patients or complex patients/situations that documentation is supporting the LOS and the concurrent stay criteria are met or to assist in expediting the discharge/transfer to a lower level of care.
        • Review payer requirements and government regulations to ensure compliant, safe, healthcare.
        • Assigns tasks to care management assistant and appropriate referrals to SW Care Coordinator to reach desired treatment outcomes.
        • Interprets problems and selects appropriate solutions based upon similar situations that have occurred in the past.
        • Plans events that are expected to occur from one to four weeks, or on a monthly basis.
        • Regularly contacts employees to discuss issues of moderate importance and to respond to inquiries. Occasionally requires

          contacts with employees at higher levels on matters requiring cooperation, explanation and persuasion.

          • Requires regular external contacts to discuss issues of moderate importance and to respond to inquiries. Also requires ongoing personal contact with the public involving matters requiring cooperation, explanation and persuasion.
          • Requires extensive knowledge of their professional discipline and a working knowledge of related fields. Understands information in several unrelated professional disciplines.


            Orlando Health is one of Florida's most comprehensive private, not-for-profit healthcare networks, and is based in Orlando, FL. Our facilities, advanced medical treatments and procedures, and highly qualified staff have distinguished Orlando Health as a healthcare leader for nearly two million Central Florida residents and 10,000 international visitors annually. Click here to learn more about Orlando Health.

Keywords: Orlando Health, St. Petersburg , Care Manager, Senior , Executive , Saint Petersburg, Florida

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