Stanford Health Care

Analyst

• Conduct thorough analyses of denials, evaluating the appropriateness of medical services and procedures.
• Maintain accurate records of appeals and denials for tracking and reporting purposes.
• Independently compose professional and comprehensive appeal letters to payors after a detailed review of medical records.
• Create comprehensive appeal strategies based on relevant guidelines and documentation to effectively address denials.
• Draft and submit detailed appeal letters along with supporting documentation, ensuring adherence to regulatory requirements and payor guidelines.
• Provide a thoughtful appealability score for each denial under review, assessing the likelihood of a successful appeal.

Clinical Government Audit Analyst, Appeal Specialist II

Director

• Responsible for day-to-day operations of radiation oncology care delivery
• Develop and manage administrative, fiscal, nursing, and technical resources
• Ensure compliance with external regulatory organizations
• Develop operating budgets and strategies for cost control
• Collaborate with clinical leadership on quality and patient safety

Director, Radiation Oncology Network – Nursing

Manager

• Inpatient & SNF Utilization Management & Care Coordination: Support proactive hospital discharge planning, transfers, and redirections through collaborative care planning.
• Develop individualized care plans for all complex case management patients, including regular updates with distribution throughout the care team.
• Proactively interface with HMOs, physicians, internal staff and family members to assist in developing a well-rounded care plan.
• Complete health risk assessments for selected senior patients as needed.
• Serves as a liaison between hospital, health plan, providers, caregivers, family, and the patient.
• Identify opportunities to improve utilization, quality of care, access issues and physician profiling.
• Acts as a resource for provider and patient education as necessary.
• Reduce avoidable inpatient and SNF bed days through telephonic & in person concurrent review, proactive assessment of barriers to discharge, and collaboration with key parties (health plan, facility, provider office, member and family) to facilitate safe and timely discharge or transition.
• Apply standard clinical criteria, document decisions and issue related member and/or provider correspondence.
• Ensure seamless and safe transition of care, through inpatient and SNF bed-side visits, post discharge coordination with members, providers and ancillary services, including related bedside visits, post-discharge calls and/or visits to members.
• Referral to telephonic case management, if appropriate.
• High Risk Member Complex Case Management: Proactively review Health Risk Assessments and at-risk patient populations for identification of patients appropriate for case management.
• Provide regular feedback to providers, inpatient case managers, and utilization management coordinators on the appropriateness of complex case management referrals.
• Develop and implement care coordination services for complex patients as needed, including scheduling appointments, home health, DME, transportation, financial assistance, and linkages with community resources.
• Identifies and refers high-risk members to delivery system chronic disease care programs to improve quality of care.
• Maintains daily electronic case management case list.
• Attends weekly interdisciplinary care team meetings to discuss complex cases and integrate input from the entire team.
• Meet production standards: Adheres to all SHC Health Plan policy and procedures
• Manages caseload of approximately 50-150 complex and/or rising risk case management patients.
• Provide telephonic and/or onsite case management for members requiring a higher level of complex case management which may include periodic visits at the member’s home or provider settings
• Complete comprehensive assessment of clinical & non-clinical risk factors impacting member’s health status.
• Develop and coordinate implementation of individualized, member centered care plans, involving member, care givers, providers and other stakeholders to ensure alignment, including scheduling appointments, home health, DME, transportation, coordinating financial assistance, and linkages with community resources.
• Effective coordination and communication with Medical Directors and clinical staff.
• All other duties as assigned including department-specific functions and responsibilities: Meet departmental review and documentation standards for work assignments. Adhere to the policy and procedure of assigned hospital(s).
• Build and maintain appropriate relationships on behalf of SHC Health Plan.
• Attend departmental and company meetings as indicated by management. Includes developing and/or presenting reports to Board directors, health plans, medical groups and other committees.
• Performs other duties as assigned and participates in organization projects as assigned.
• Adheres to safety, P4P’s (if applicable), HIPAA and compliance policies.

Clinical Government Audit Analyst, Appeal Specialist II

Director, Radiation Oncology Network – Nursing

CARE MANAGER