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Job description
Introduction
To heal, to teach, to discover and to advance the health of the communities we serve.
Overview
The RN Case Manager Utilization Management is responsible for supporting the physician and interdisciplinary team in facilitating patient care, at the appropriate level of care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payors.
Responsibilities
The individual in this position has primary responsibility for ensuring that care provided is at the appropriate level of care based on medical necessity.
This position manages the medical necessity review process to ensure accurate and timely payment for services.
This role integrates and coordinates utilization management by performing clinically based medical necessity reviews using standardized published criteria to certify medical necessity for admission and continued stay of all patients receiving care in the hospital.
Progression of care is managed by using bench marked evidence-based criteria (i.e., InterQual).
Requirements
Education/Training :
Graduate of NLN Accredited School of Nursing, BSN preferred.
Ability to read, write, and communicate in English.
Experience :
3 years of experience as a Utilization Review/Utilization Management (UR/UM) Nurse or Nurse Case Manager with primary responsibility for UR/UM in an acute care setting required.
Experience with EPIC EMR.
Proficiency in applying InterQual guidelines for medical necessity.
Familiarity with processes of critical payers such as Aetna, UHC, MVP, BCBS.
Must have experience forming positive, collaborative relationships with hospital staff, providers, patients, and families.
Must demonstrate critical thinking skills to find solutions to problems, work independently, manage stress, prioritize work, and maintain calm demeanor in stressful environment.
Licensure:
Current New York State Licensure as a Registered Professional Nurse.
Certification in Case Management required 18 months after eligibility.
NYS PRI and Screen certification required within 3 months of hire/transfer.
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Who can apply
Review the original listing for work authorization, qualifications and employer requirements.