About The Position
The Care Manager (RN) uses clinical expertise, patient assessments, and insurance payer requirements to coordinate patient needs throughout the continuum of care, including post-acute care and discharge planning. The role reviews clinician assessments and patients’ financial, family, and psychosocial support to provide justification for hospitalization during clinical reviews. The Care Manager reviews records to assess appropriate admission status, level of care, payer source, and utilization review contracts to validate billing. The role documents pertinent patient issues, contacts, and discharge plans in medical reviews; communicates with physicians and medical offices to confirm insurance authorizations; and assists with justification for insurance appeals and denials. The Care Manager may also educate patients and families about appropriate changes in level of care.
Requirements
- Five years of clinical experience in an acute healthcare system environment.
- Experience with InterQual or Millennium Guidelines.
- One year of experience in utilization review.
- Experience with healthcare database systems.
- Bachelor’s or master’s degree in Nursing (BSN/MSN).
- Registered Nurse (RN) license.
Nice To Haves
- Utilization Review, Care Management, or Clinical Nursing certification (listed as preferred certifications).
Responsibilities
- Coordinate patient needs across the continuum of care, including post-acute care and discharge planning.
- Review clinician assessments and patients’ financial, family, and psychosocial support to justify hospitalization for clinical reviews.
- Review records to assess admission status, level of care, payer source, and utilization review contracts for billing validation.
- Document pertinent patient issues, contacts, and discharge plans on medical reviews.
- Communicate with physicians and medical offices to confirm appropriate insurance authorizations are in place.
- Assist with justification for insurance appeals and denials as needed.
- Educate patients and families about appropriate level-of-care changes when needed.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
