RN Case Manager - Utilization Review

Job Details

Description

Position Summary : The Utilization Review Case Manager validates the patients placement to be at the most appropriate level of care based on nationally accepted admission criteria. The UR Case Manager uses medical necessity screening tools, such as InterQual or MCG criteria, to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests / procedures and an estimation of the patients expected length of stay. The UR Case Manager secures authorization for the patients clinical services through timely collaboration and communication with payers as required. The UR Case Manager follows the UR process as defined in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review.

Experience

• Required : 3 to 5 years acute care nursing experience
• Preferred : Experience in case management

Education

License and Credentials

Required Skills

Current sound clinical knowledge; knowledge of medical literature, research methodology, financial / reimbursement issues. Strong collaboration, communication and interpersonal skills. Excellent organizational and time management skills. Knowledge of computers, Electronic Health Records, data base systems and utilization review / case management documentation systems. Desire to work collaboratively and proactively with healthcare teams and other hospital-based interdisciplinary teams. Current knowledge of discharge planning, resource management, and care coordination in an acute care setting. Knowledge of CMS, commercial payer requirements and hospital financial / reimbursement processes. Excellent written / verbal communication skills, critical thinking skills, creative problem solving skills, good organizational and planning skills. Must be self-directed, have the ability to tolerate frequent interruption and work in a fast-paced work environment. Knowledge of funding, resources, services, clinical standards, care coordination processes and outcomes is preferred. Weekend, Holiday and on call may be required.

Bi-Weekly Hours : 80

Work Schedule : M - F (Weekends, Holidays, or On Call may be required)

The minimum starting rate for this position is $40.67

When determining a team members base rate, several factors may be considered as applicable (e.g., years of recent relevant experience, education, credentials, and internal equity).

At Deborah, healthcare is still about caring...for patients and team members. That is why we offer an outstanding benefits package, which includes healthcare coverage for team members in regularly budgeted positions of at least 30 hours per week. The benefits package also includes generous paid time-off, 401K matching contribution, tuition assistance, short and long term disability benefits, life insurance, meal discount, dependent care subsidy, adoption assistance and free parking.

Qualifications

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Education

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Preferred

Bachelor Science Nursing or better in Nursing.

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Licenses & Certifications

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Required

Registered Prof. Nurse

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Equal Opportunity Employer

This employer is required to notify all applicants of their rights pursuant to federal employment laws.

For further information, please review the Know Your Rights notice from the Department of Labor.