Case Manager EX - Utilization Management
New
J
JobgetherHealthcare
Based in United StatesFull-TimeMiddle
Salary not disclosed
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Job Details
- Languages
- English
- Experience
- Minimum of 5 years of clinical experience and at least 1 year of case management experience preferred.
- Required Skills
- Microsoft Office
Requirements
- Current Registered Nurse (RN) license required.
- Bachelor of Science in Nursing (BSN) required for external candidates.
- Minimum of 5 years of clinical experience and at least 1 year of case management experience preferred.
- Strong understanding of patient acuity levels and clinical documentation requirements.
- Knowledge of utilization management practices and healthcare regulatory standards, including Joint Commission, CMS, CDPH, and CCS requirements.
- Excellent written and verbal communication skills in English.
- Strong customer service skills and ability to collaborate effectively with multidisciplinary teams.
- Proficiency with computer systems and software, including Microsoft Office applications such as Word, Excel, PowerPoint, and Outlook.
- Ability to manage multiple projects and maintain productivity in a fast-paced healthcare environment.
- Strong analytical, organizational, and problem-solving skills.
- Ability to establish and maintain effective professional relationships across healthcare departments.
- Familiarity with California Children’s Services (CCS) authorization processes is preferred.
- CCM or ACM certification is preferred.
Responsibilities
- Implement utilization management processes for hospitalized patients, reviewing admissions and ongoing care needs.
- Monitor and coordinate healthcare resource utilization while evaluating services provided across the health system.
- Perform utilization reviews using approved clinical decision support criteria, including severity and intensity-of-service guidelines.
- Analyze utilization patterns, trends, and clinical data to support operational improvements and quality initiatives.
- Participate in denial management activities, audits, special studies, and utilization monitoring projects.
- Review medical records and collaborate with physicians to improve clinical documentation accuracy and ensure patient conditions are properly reflected.
- Support initiatives that enhance care quality, compliance, and efficient healthcare delivery.
- Maintain accurate documentation and reporting related to utilization management activities.
- Build effective working relationships with physicians, nurses, administrative teams, and other healthcare professionals.
- Contribute to process improvement efforts that support patient outcomes and organizational goals.
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