About this opportunity
Community First Medical Center lists this Case Manager - Utilization Review RN opportunity in chicago, Illinois. Review the employer’s description below for duties, qualifications and application requirements.
Job description
Under the general direction of the Director of Behavioral Health, the Case Manager - Utilization Review RN provides clinically based case management and utilization review services to support the delivery of high-quality, cost-effective patient care. The RN is responsible for concurrent utilization review, medical necessity determination, denial prevention, discharge planning, care coordination, and resource management across the continuum of care.
The Case Manager - Utilization Review RN collaborates with physicians, interdisciplinary team members, physician advisors, social workers, revenue cycle staff, and third-party payers to ensure appropriate utilization of hospital resources, regulatory compliance, optimal reimbursement, and safe patient transitions.
Community First Medical Center offers benefits to all its full-time and part-time employees :
United Healthcare Medical PPO/HMO/HSA Plans, premiums as low as $50.00/full time, $85.00/Part Time
Met Life Dental and Vision
Paid Time Off (PTO) with annual accruals up to 168 hrs./year
Six paid holidays
Company Paid Life insurance and Short-term Disability
401(k) after 90 days
Continuing Education reimbursement and 2 days paid off separate from PTO
Free Parking Garage
Internal Growth Opportunities
Requirements
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
QUALIFICATIONS
Education Associate Degree in Nursing required.
Bachelor of Science in Nursing (BSN) preferred.
Experience Minimum three (3) years of acute care nursing experience required.
Minimum two (2) years of Case Management and/or Utilization Review experience preferred.
Experience with discharge planning, utilization review, denial management, and payer authorization preferred.
Licensure Current Illinois Registered Nurse license required.
ACM, CCM, or CMAC certification preferred.
KNOWLEDGE, SKILLS & ABILITIES Knowledge of Medicare, Medicaid, and commercial insurance regulations.
Working knowledge of InterQual and/or MCG criteria.
Behavioral Health background knowledge
Access to Behavioral Health Networks
Understanding of utilization management and care coordination principles.
Knowledge of discharge planning and post-acute care resources.
Strong analytical and critical thinking skills.
Excellent verbal and written communication skills.
Ability to prioritize multiple complex patient cases.
Ability to build collaborative relationships with physicians and interdisciplinary teams.
Computer proficiency and electronic medical record experience.
PERFORMANCE EXPECTATIONS
Success in this role is measured by: Appropriate admission status determination
Denial prevention and appeal success
Timely discharge planning
Reduction in avoidable days
Average Length of Stay management
Readmission reduction
Documentation compliance
Regulatory compliance
Patient throughput
Patient and physician satisfaction
Salary Description
43.47-$53.00
Worksite address
chicago, IL, 60290, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.