Case Manager - Utilization Review RN
About The Position
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.
Requirements
- Associate Degree in Nursing required.
- Current Illinois Registered Nurse license required.
- Minimum three (3) years of acute care nursing experience required.
- 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.
Nice To Haves
- Bachelor of Science in Nursing (BSN) preferred.
- 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.
- ACM, CCM, or CMAC certification preferred.
Responsibilities
- Concurrent utilization review
- Medical necessity determination
- Denial prevention
- Discharge planning
- Care coordination
- Resource management across the continuum of care
- Collaboration 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.
Benefits
- 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
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
