The Community Care Clinical Coordinator is a staff nurse whose specific role includes organizing and coordinating the clinical components for the authorization of Community Care services in response to individual healthcare needs along the illness and care continuum and in multiple settings. The goals are to center services around the patient, to foster patient self-managed care, and maximize efficient and cost-effective use of health care resources. DESCRIPTION OF SERVICE/DEPT-SPECIFIC DUTIES: - Utilizes comprehensive knowledge of advanced clinical practice and case management principles to asses appropriate level of care and to ensure compliance with established Community Care authorities and guidelines resulting in approvals and/or denials for Community Care - Reviews medical referrals/appointments and general hospital procedures by monitoring specialty care referrals for appropriateness, covered benefits, and authorized surgery/medical procedures, laboratory, radiology and pharmacy. - Performs review for planned inpatient and outpatient surgery; and performs concurrent review to include length of stay (LOS) for the facility's inpatients using appropriate criteria. - Acts as referral approval authority for designated referrals per Community Care guidance and standards. - Ensures and monitors specialty care referrals for appropriateness, medical necessity, and if the appointment, diagnostic testing, or procedure requested is a covered benefit according to Community Care eligibility. - Receives and makes patient telephone calls, written, or e-mail correspondence regarding specialty clinic appointments and referrals. - Responsible for performing prior authorization review of services that require notification, using applicable benefit package and specific recognized clinical guidelines and criteria. - Interacts with providers to obtain clinical information to support prior authorization determinations and provide support for their questions. - Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. - Work in collaboration with co-workers to ensure timely and efficient completion of all workflows within the Department. Work Schedule: Monday - Friday, 7:30 am - 4:00pm Financial Disclosure Report: Not required
Internal Number: 599373900
About Veterans Affairs, Veterans Health Administration
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.