Job Description
Are you a compassionate and detail-oriented Registered Nurse with a passion for ensuring patients receive the highest quality, most efficient care? If so, we're looking for you! We're seeking a dedicated Utilization and Case Management Specialist to join our team and play a vital role in optimizing healthcare delivery.
About the Role:
In this dynamic role, you'll be at the forefront of ensuring patients receive appropriate, cost-effective care. You'll use your clinical expertise and knowledge of utilization management principles to review patient cases, determine medical necessity, and collaborate with healthcare providers to optimize resource utilization. You'll be a key player in ensuring patients receive the right care, in the right setting, at the right time.
What You'll Do:
Clinical Review and Assessment:
Conduct thorough reviews of patient cases, utilizing clinical information, established criteria, and payer guidelines to determine the medical necessity of admissions, continued stays, and levels of care.
Identify opportunities to enhance the cost-effectiveness of care, focusing on areas such as length of stay, medication management, therapies, and diagnostic testing.
Collaborate with the Medical Director to address cases that do not meet established criteria.
Liaison and Collaboration:
Serve as a vital link between the case management team, third-party payers, and the treatment team, ensuring seamless communication and coordination regarding treatment plans.
Work closely with physicians and office staff to resolve authorization questions and issues.
Educate physicians and staff on appropriate levels of care and utilization management principles.
Care Coordination and Planning:
Assist the patient care team in identifying and coordinating alternative treatment settings that provide appropriate care while maintaining quality and reducing costs.
Identify patients who would benefit from care management programs, including complex care management, and facilitate referrals.
Collaborate with the interdisciplinary team to determine patient needs.
Data Analysis and Education:
Contribute to the collection and analysis of utilization patterns and denied cases.
Prepare and present utilization data analysis reports as required.
Develop and deliver educational programs on utilization management principles.
Documentation and Compliance:
Maintain accurate and comprehensive documentation in accordance with established policies and procedures.
Adhere to all quality assessment and safety standards.
Customer Service and Teamwork:
Provide exceptional service to all customers, fostering a collaborative and supportive team environment.
Practice fiscal responsibility through continuous improvement and innovation.
What We're Looking For:
Education: Associate's Degree in Nursing required.
Licensure: Active Registered Nurse (RN) license required, or a Multi-State RN license.
Experience:
Minimum of 3 years of relevant clinical experience.
Preferred experience in utilization management, case management, or a clinical nursing specialty.
Preferred experience in Human Resources with leave of absence administration or management.
Skills:
Strong clinical assessment and critical thinking skills.
Excellent communication and interpersonal skills.
Proficiency in data analysis and reporting.
Ability to work independently and as part of a team.
Knowledge of managed care agreements and payer guidelines.
Why Join Us?
Be part of a team dedicated to providing high-quality, patient-centered care.
Make a meaningful impact on the lives of patients and their families.
Enjoy a supportive and collaborative work environment.
Opportunities for professional growth and development.
Employment Type: Full-Time
Salary: $ 34.00 Per Hour
Job Tags
Hourly pay, Full time,