GENERAL SUMMARY:

Facilitates admission and registration process for scheduled inpatients and CARES surgical patients. Obtains essential information for registration and insurance pre-certification. Responsible for pre-certification of anticipated care needs on behalf of Children’s Hospital and designated physicians with third party payers. Establishes good rapport with and maintains effective communications with patients, their parents, physicians, nursing staff and third party payors.

ESSENTIAL FUNCTIONS/COMPETENCIES

• Receives notification of admissions from physicians and/or their agents, the surgery scheduling department and clinics.
• Obtains pertinent information, i.e., name of patient, date of admission, diagnosis, date of birth, admission status, phone numbers and insurance information, to initiate a reservation and enters data into computer.
• Assembles appropriate forms for admission.
• Initiate Admission Assessment Form.
• Effectively communicates and collaborates with physicians, physician office personnel, specialty nurses and other hospital departments to obtain medical history, physician orders, and other anticipated care needs prior to date of service.
• Demonstrates effective communication skills in interviewing families to obtain complete and accurate demographic and insurance information assess guardianship issues and perform nursing assessment for specific needs and anticipated service referrals during and after hospitalization.
• Demonstrates effective teaching when parent/patient instructions are needed to ensure appropriate preparation for admission and testing.
• Identifies all payment sources and pre-admission certification requirements to prevent denials and/or reduction of benefits and enters data into computer.
• Demonstrates effective relationship & develops working knowledge of requirements for third party payors.
• Obtains and documents authorization numbers from third party payors for outpatient surgical patients and TD procedures.
• Obtains necessary paper referrals from Primary Care Physician and/or Specialty Physician when required by third party payors.
• Secures responsible parties signature on “Self-Pay” form for those patients identified with no insurance coverage or on those patients whose insurance will not cover services/procedures
• Provides initial notification and clinical assessment to insurance company, certifying initial days of care; prior to service whenever possible.
• Verifies patient eligibility with insurance co. for unscheduled admissions.
• Works with nursing case managers to initiate the utilization management process.
• Certifies initial days of care and appropriate length of stays for scheduled and/or CARES inpatients.
• Assesses all admission procedures and specified outpatient diagnostic tests/procedures for appropriateness of level of care using pre-established criteria, whenever possible.
• Provides support to the Access Center Registrar and to physicians offices to ensure a timely, expedient and accurate admission process.
• Clinical responsibilities include subcutaneous and intramuscular injections, central line draws, catheterized UA’s and obtaining wound cultures.
• Coordinates scheduling of tests ie: audio, neuro, and cardio, CT/MRI, with ordering physician, family and responsible department.
• Demonstrates the ability to accurately use SCM for order entry, deletion and activation of patient orders

COMPETENCIES

• Mentor to staff learning to pre-cert
• Carries assigned tasks to completion
• Performs other duties as assigned

KNOWLEDGE, SKILLS AND ABILITIES:

• Good Verbal and Written Skills
• Computer knowledge
• Ability to work with minimal supervision
• Knowledge of ICD-9 and CPT-4 coding regulations
• Knowledge of the principles of pediatric nursing.
• Knowledge of the changing rules and regulations of third party payors

Skills

• Team building
• Service excellence
• Problem solving skills
• Basic Life Support certification

Abilities

• Computer literacy
• Ability to handle multiple priorities successfully
• Adapt quickly to new techniques and work methods

EDUCATION AND EXPERIENCE:

• Education- Current registered nurse with licensure in the State of Nebraska Experience-Minimum of 3 years of clinical pediatric experience
• Prefer 1 year of managed care experience with insurance verification and pre-certification
• URAC or UMAC strongly encouraged.