Case Manager – Utilization Management
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Job Description
Part-time remote Utilization Management Case Manager reviewing admissions and patient class assignments for Lehigh Valley Health Network. Ensuring payer compliance and maximizing reimbursement.
Responsibilities:
- Review all hospital admissions and evaluate admission appropriateness using approved criteria
- Ensure appropriate inpatient or outpatient patient class assignment and compliance with third party payer requirements
- Educate staff on appropriate level of care assignment, patient class, and utilization management
- Provide timely, accurate, and thorough clinical reviews for patient class decisions
- Develop and implement methods, policies, and procedures to improve departmental efficiency
- Partner with unit-based care managers regarding patient financial status, diagnosis, and discharge needs
- Collaborate with precert/preservices, appeals, patient access, billing, coding, and finance teams
- Complete clinical reviews using evidence-based criteria
- Collaborate with management, peers, and colleagues to facilitate patient class assignment, resolve complex cases, and maximize reimbursement
- Perform patient class changes as directed by the physician advisor, attending provider, and/or payer
- Document authorizations and downgrades according to policy
- Participate in performance improvement activities, including assessment, implementation, and evaluation of processes
Requirements:
- Specialized Diploma in nursing
- 2 years of previous utilization review experience
- Knowledge of utilization management as it relates to third party payers
- Ability to maintain strict HIPAA adherence and confidentiality of PHI
- Ability to work in a team environment and demonstrate flexibility
- Attention to detail and positive attitude
- Ability to complete assignments accurately and timely while managing multiple responsibilities and priorities
- Proficiency with all work queue processes
- Knowledge of evidence-based clinical decision support criteria
- RN - Licensed Registered Nurse, Pennsylvania state license, upon hire
- Preferred: Bachelor’s Degree in nursing
- Preferred: Knowledge of InterQual and/or MCG criteria
- Preferred: ACM, ACMA, CCM, or CMCN certification with Pennsylvania certification/credential requirements upon hire
Benefits:
- Equal opportunity employment
- Educational programs and/or social activities
- Benefits are referenced as part of the employer's personnel programs, but no specific benefit details are provided
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