Case Manager RN / RAC Audit Coordinator - AHS - Sherman Medical Center

This is a combined role position.

Responsible for the quality and resource management of all patients that are admitted to the facility from the point of their admission and across the continuum of the health care management.  Works on behalf of the advocate, promoting cost containment and demonstrates leadership to integrate the health care providers to achieve a perceived seamless delivery of care.  The methodology is designed to facilitate and insure the achievement of quality, clinical and cost effective outcomes and to perform a holistic and comprehensive concurrent review of the medical record for the medical necessity, intensity of service and severity of illness. 

The RAC Audit Coordinator, as needed, serves as the internal primary contact and representative regarding any communication received about RAC audit requests. Is knowledgeable in the specific functions of the position, and serves as a resource for co-workers.  The RAC Audit Coordinator is responsible for maintaining integrity of tracking government review audits (RAC, MAC, CERT, ADR, Pre/Post Probes, and MEDICAID), Payer DRG reviews and changes and other external audit requests as they are created / received.  Position is responsible for logging and tracking all incoming requests and updating electronic log when requests are responded to and actions as they occur.  Position is also responsible for aggregating, analyzing, and reporting denials data to the Utilization Review function/committee on a regular basis.

Education, Experience, Training

1.  Current Registered Nurse license from the state of Texas required.

2.  Five years acute care nursing experience preferred.  At least one year experience in case management, discharge planning or nursing management preferred.

3.  Current BLS certificate required.