Case Manager - Utilization Management
New
L
Lehigh Valley Health NetworkHealth care
REMOTE IN PENNSYLVANIAFull-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- 2 years of previous utilization review experience. and 2 years Knowledge of utilization management as it relates to third party payers.
- Required Skills
- HIPAA
Requirements
- Specialized Diploma in nursing.
- Two years of previous utilization review experience.
- Two years of knowledge of utilization management as it relates to third-party payers.
- Pennsylvania-licensed Registered Nurse (RN) upon hire.
- Knowledge of evidence-based clinical decision-support criteria.
- Proficiency with work queue processes.
- Maintain HIPAA confidentiality and protect patient health information.
- Preferred: Bachelor's degree in nursing.
- Preferred: Knowledge of InterQual and/or MCG criteria.
- Preferred: ACM, CCM, and/or CMCN certification.
Responsibilities
- Review hospital admissions and evaluate whether admission is appropriate using approved, evidence-based criteria.
- Assess the appropriate level of care and patient class, including inpatient or outpatient assignment.
- Provide timely, accurate clinical reviews to support patient-class decisions.
- Educate staff and serve as a resource on level-of-care assignment, patient class, and utilization management.
- Partner with unit-based care managers to exchange information about patient financial status, diagnosis, and discharge needs.
- Coordinate reviews with precertification, appeals, patient access, billing, coding, and finance teams.
- Collaborate with management, peers, and other colleagues to resolve complex cases and support appropriate patient-class assignment and reimbursement.
- Process patient-class changes and document authorizations and downgrades according to policy.
- Participate in performance improvement by assessing, implementing, and evaluating updated processes.
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