Case Manager - Utilization Management

Lehigh Valley Health Network•REMOTE IN PENNSYLVANIA, PA

2d•Remote

About The Position

The Case Manager - Utilization Management ensures appropriate use of hospital resources by reviewing patients admitted to the hospital and evaluating admission appropriateness using approved criteria. The role ensures that patients are assigned the appropriate class, such as inpatient or outpatient, in compliance with third-party payer requirements. This position is remote in Pennsylvania and works an eight-hour day shift, Monday through Friday, with weekend and holiday coverage.

Requirements

Specialized Diploma in nursing.
Two years of previous utilization review experience.
Two years of knowledge of utilization management as it relates to third-party payers.
Maintain strict adherence to HIPAA and confidentiality of all protected health information.
Ability to work in a team environment and demonstrate flexibility in working toward common goals based on prioritized needs.
Attention to detail and a positive attitude.
Ability to complete assignments accurately and on time while managing multiple responsibilities and prioritizing tasks effectively.
Proficiency with all work-queue processes.
Knowledge of evidence-based clinical decision-support criteria.
Registered Nurse license in Pennsylvania upon hire.

Nice To Haves

Bachelor’s degree in nursing.
Knowledge of evidence-based criteria such as InterQual and/or MCG criteria.
Accredited Case Manager (ACM) certification in Pennsylvania upon hire.
Certified Case Manager (CCM) certification in Pennsylvania upon hire.
Certified Managed Care Nurse (CMCN) certification in Pennsylvania upon hire.

Responsibilities

Act as a resource and provide education on appropriate level-of-care assignment, patient class, and utilization-management-related work.
Provide timely, accurate, and thorough clinical reviews to support patient-class decision-making.
Develop and implement methods, policies, and procedures to improve departmental efficiency and effectiveness.
Partner with unit-based care managers to ensure appropriate exchange of information regarding patient financial status, diagnosis, and discharge needs.
Coordinate with precertification/preservices, appeals, patient access, billing, coding, and finance to complete reviews thoroughly and accurately.
Complete clinical reviews and evaluate admission appropriateness using evidence-based criteria.
Collaborate with management, peers, and colleagues outside the department to facilitate appropriate patient-class assignment, resolve complex cases, and investigate cases to maximize reimbursement.
Complete patient-class changes promptly and efficiently at the direction of the physician advisor or attending provider, and/or in conjunction with the appropriate payer.
Document authorizations and downgrades according to departmental policy and procedure.
Participate in performance improvement by assessing, implementing, and evaluating new or updated processes to meet annual goals and streamline procedures.