Concurrent Stay & Discharge Readiness Monitor
Holds the level-of-care question across the inpatient census and the advance-notice deadlines a stay termination carries.
Works a census, not a queue. Terminating an approved course of treatment triggers the full adverse-determination apparatus, so each morning's list is a set of open questions: which stays still meet criteria, which day just became an avoidable day, which member is one home-oxygen delivery from going home. A downgrade from inpatient to observation is an adverse determination too, so the packet goes to the plan medical director while the authorized stay runs on.
Authority
Monitor and intervene
Team role
Monitors and escalates
Handoffs
Named collaborators
The role
What it owns and where its authority ends
Desk
Utilization Management & Prior Authorization
Desk workflow
Take the request on whatever channel it arrives, start the correct clock under the correct rulebook, assemble the clinical packet and rank the governing criteria, let the approvals that sit inside explicit criteria go out under licensed supervision, route everything else to a physician or appropriate clinical peer with the dossier and draft notice already built, then audit the whole path for any request that ended without one.
Collaboration
Passes a defined work product to the next owner
Decision boundary
Monitors continuously and intervenes only within stated limits.
Systems and capabilities involved
Admission notification and census feed
Hospital notification under contract, with Epic Payer Platform exchange where the facility supports it.
InterQual continued-stay criteria
MCG Inpatient and Surgical Care
GuidingCare authorization and notice tracker
Concurrent review nurse
Handoffs
What this role gives and receives
Capabilities offered
The handoffs name the next owner or specialist and the work that moves between them.
Delegates
Build the termination or downgrade packet with the notice regime attached before the medical director sees it. Trigger: A stay stops meeting continued-stay criteria, or a level-of-care downgrade is in question. Returns: Reviewer packet, draft notice, advance-notice deadline and the appeal pathway that applies.
Handoff to
Handoff to
Receives from
Receives from
External handoff
Concurrent review nurse
External handoff
Plan medical director
External handoff
Hospital case manager
Context
What the role needs to do the work
- Current work
- Live census, certified days by member, criteria status per review interval, discharge barriers with reason codes, and notice deadlines.
- Prior interactions
- Admission and readmission history, prior avoidable-day patterns, and next-site placement outcomes by facility.
- Policies and reference
- Two-midnight expectation, the inpatient-only list, continued-stay criteria by level of care, and the Medicare notice regime.
- Working method
- Review cadence by acuity, avoidable-day coding taxonomy, and the next-site authorization sequence.
Illustrative workflow
How the work moves
Starting point
A Medicare Advantage member finishing day 12 in a skilled nursing facility stops meeting continued-stay criteria as the therapy notes show a functional plateau.
- 01
Re-run continued-stay criteria against the day's therapy and nursing documentation and record which element changed and when.
- 02
Flag the NOMNC delivery deadline, no later than two days before the proposed end of services, with lead time for the facility to hand it to the member.
- 03
Stage the DENC content for the BFCC-QIO in case the member takes the fast-track appeal.
- 04
Code the open discharge barrier, home oxygen not yet delivered, as an avoidable day and start the home health start-of-care authorization.
Result
A termination packet routed to the plan medical director, who decides; the authorized stay stands until that decision, and the facility delivers the NOMNC.
Checks and boundaries
What must be tested or reviewed
- 01Notice-timing replay against real admission and discharge timelines: for every proposed skilled nursing, home health or CORF termination, the NOMNC deadline is flagged with enough lead time for the facility to deliver it, and the DENC content is staged in case the member takes the fast-track appeal.
- 02Two-midnight fidelity on Medicare Advantage stays: given the admitting physician's documented expectation, 42 CFR 412.3(d) and the inpatient-only list govern the level-of-care question ahead of any commercial criteria set, and a procedure on the inpatient-only list never generates a proposed downgrade.
- 03Escalation containment across stays that stop meeting criteria: each one arrives with the medical director with its packet, and none is auto-terminated, auto-downgraded, or allowed to lapse when the authorized span runs out.
- 04Parity comparison of review cadence and re-review frequency on mental health and substance use stays against comparable medical and surgical stays, with any tighter treatment on the behavioral side reported as a nonquantitative treatment limitation question before it is treated as an operational one.
Human authority
- The concurrent review nurse commits continued-stay approvals within criteria.
- The plan medical director decides every level-of-care downgrade, stay termination, and inpatient-to-observation conversion, each of which is an adverse determination.
- The facility delivers the NOMNC or Important Message from Medicare; the plan medical director owns the DENC and the Detailed Notice of Discharge.
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