Job Summary and Qualifications The Case Manager’s primary duties are to provide Utilization Review and Case Management functions for the organization under the direction of the Director, Case Management and within the established policies and procedures. The role performs preadmission, concurrent, and retrospective review for all payers, completes assessments to identify discharge‑planning needs, and provides discharge‑planning services for select patient populations. It requires proficiency in InterQual. Responsibilities Performs continuous assessments and evaluations to ensure patients are progressing toward desired outcomes. Assesses and responds to patient/family needs by coordinating efforts of other team members. Identifies and resolves barriers that hinder effective patient care. Collaborates and consults with physicians on patient’s progress and discharge planning needs. Performs utilization review to ensure admissions meet criteria for appropriateness of care and medical necessity. Manages the process to review and, as appropriate, appeal denials received from payers. Coordinates the discharge planning process, ensuring involvement of all members of the healthcare team. Counsels with patients and family members in decision making and in meeting psycho‑social needs of the patient. Maintains knowledge of resources and facilities available to patients and family members. Collaborates with personnel at other facilities to coordinate smooth and effective patient transfers and transitions. Compiles, evaluates, and reports statistics to members of the team and utilizes the information to facilitate process improvement activities. Applies knowledge of the patient population served; proves age‑specific care; applies knowledge of expected norms in planning care. Promotes internal and external customer satisfaction. Builds and promotes a culture of service excellence and continuous improvement. Attends work as scheduled and complies with Attendance and Tardiness Policy. Qualifications Required: Registered Nurse Licensure. Preferred: Bachelor’s or Master’s of Science in Nursing; knowledge of CMS guidelines and experience working with payer‑specific guidelines and contractual rules; previous UR or hospital Case Management experience. One to three years of experience in a hospital or health care system. Assertive and persuasive communication skills; action oriented. Benefits Comprehensive benefits for medical, prescription drug, dental, vision, behavioral health and telemedicine services. Well‑being support, including free counseling and referral services. Time‑away-from-work programs for paid time off, paid family leave, long‑ and short‑term disability coverage and leaves of absence. Savings and retirement resources, including a 401(k) plan with a 100% match on 3% to 9% of pay, Employee Stock Purchase Plan, flexible spending accounts, preferred banking partnerships, retirement readiness tools, rollover support and financial well‑being counseling. Education support through tuition assistance, student loan assistance, certification support, dependent scholarships and a partnership with Galen College of Nursing. Additional benefits for fertility and family building, adoption assistance, life insurance, supplemental health protection plans, auto and home insurance, legal counseling, identity theft protection and consumer discounts. We are an equal‑opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status. #J-18808-Ljbffr
Case Manager RN • Portsmouth, NH, United States
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