Case Manager – Utilization Management

This is a fully remote position, open to applicants in Pennsylvania.

📋 Description

• Conduct reviews of all hospitalized patients to assess the appropriateness of their admissions using established criteria.

• Ensure correct assignment of inpatient or outpatient patient classifications and adherence to third-party payer regulations.

• Provide education to staff regarding suitable level-of-care classifications, patient categories, and utilization management processes.

• Deliver prompt, accurate, and comprehensive clinical evaluations for patient classification determinations.

• Create and implement strategies, policies, and procedures to enhance departmental efficiency.

• Collaborate with unit-based care managers on matters related to patient financial status, diagnoses, and discharge requirements.

• Coordinate efforts with precertification, appeals, patient access, billing, coding, and finance teams.

• Evaluate admission appropriateness using data-driven criteria.

• Work together on intricate cases, patient class assignments, and strategies for optimizing reimbursement.

• Execute patient class modifications as directed by physician advisors, attending providers, and payers.

• Maintain documentation for authorizations and downgrades.

• Engage in performance improvement assessments, implementations, and evaluations.

⛳️ Requirements

• Specialized Diploma in nursing.

• 2 years of prior experience in utilization review.

• 2 years of knowledge related to utilization management concerning third-party payers.

• Capability to uphold strict HIPAA compliance and safeguard the confidentiality of all PHI.

• Ability to work collaboratively in a team-oriented environment and exhibit adaptability.

• Strong attention to detail and a positive demeanor.

• Competence in completing tasks accurately and promptly while juggling multiple responsibilities.

• Proficient in all work queue processes.

• Familiarity with evidence-based clinical decision support criteria.

• RN - Licensed Registered Nurse in the State of Pennsylvania upon hire.

• Preferred: Bachelor’s Degree in nursing.

• Preferred: Knowledge of InterQual and/or MCG criteria.

• Preferred: ACM, ACMA, CCM, and/or CMCN certifications in Pennsylvania upon hire.

🏝️ Benefits

• Full-time employment.

• Day shift schedule.

• Remote work available in Pennsylvania.

• Equal employment opportunity.

• 8-hour work schedule from Monday to Friday, with weekend and holiday coverage.