Case Manager – Utilization Management

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

📋 Description

• Assess all hospital admissions and determine their appropriateness based on established criteria.

• Ensure correct assignment of inpatient or outpatient patient classifications while adhering to third-party payer requirements.

• Train staff on the proper assignment of care levels, patient classifications, and utilization management practices.

• Deliver prompt, precise, and comprehensive clinical evaluations for decisions regarding patient classifications.

• Create and enforce methods, policies, and procedures aimed at enhancing departmental efficiency.

• Collaborate with unit-based care managers concerning patients' financial situations, diagnoses, and discharge requirements.

• Work alongside precertification/preservices, appeals, patient access, billing, coding, and finance teams.

• Conduct clinical evaluations using evidence-based criteria.

• Partner with management, peers, and colleagues to facilitate patient classification assignments, address complex cases, and optimize reimbursement.

• Execute patient classification changes as instructed by the physician advisor, attending provider, or payer.

• Record authorizations and downgrades in accordance with policy.

• Engage in performance improvement initiatives, which include assessing, implementing, and evaluating processes.

⛳️ Requirements

• Specialized Diploma in nursing.

• A minimum of 2 years of prior experience in utilization review.

• Understanding of utilization management as it pertains to third-party payers.

• Capability to uphold strict HIPAA compliance and maintain confidentiality of protected health information (PHI).

• Ability to thrive in a team-oriented environment and exhibit flexibility.

• Strong attention to detail and a positive outlook.

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

• Proficiency in all work queue processes.

• Familiarity with evidence-based clinical decision support criteria.

• RN - Licensed Registered Nurse, must possess a Pennsylvania state license upon hire.

• Preferred: Bachelor’s Degree in nursing.

• Preferred: Familiarity with InterQual and/or MCG criteria.

• Preferred: ACM, ACMA, CCM, or CMCN certification with Pennsylvania certification/credential requirements to be fulfilled upon hire.

🏝️ Benefits

• Equal opportunity employment.

• Access to educational programs and/or social activities.

• Benefits are mentioned as part of the employer's personnel programs, but specific details regarding benefits are not provided.