Case Manager - Utilization Review

$93,704 - $132,350/Yr

Vail Health - Edwards, CO

Full-time - Entry Level

Edwards, CO

Hospitals

About the position

Vail Health has become the world's most advanced mountain healthcare system, consisting of a 520,000-square-foot, 56-bed hospital that provides exceptional care to all patients. The Precourt Healing Center, a new state-of-the-art behavioral health inpatient center, is set to open soon, focusing on treating the whole person by addressing their physical, emotional, and psychological needs. The organization strives to be a model of integrated and exceptional behavioral health treatment, research, education, and innovation, promoting a full continuum of care across Mountain Communities.

Responsibilities

• Monitors for appropriateness of admission, continued stay, and readiness for discharge based on medical necessity as evidenced by appropriate documentation.
• Demonstrates medical necessity using InterQual criteria.
• Maintains continuous and effective communication with Providers to ensure complete documentation reflecting medical necessity to support appropriate patient status orders and compliance with CMS regulations as related to utilization management.
• Collaborates with third party payers by providing timely clinical documentation and seeking authorization as needed in partnership with Insurance Verification.
• Facilitates appeals based on documented medical necessity in partnership with attending Providers. Collaborates with denials management team to navigate appeals process.
• Participates in internal auditing, data tracking and reporting through the Utilization Review Committee to ensure best practice.
• Supports the needs of the Case Management department and the organization within scope of practice, as needed.
• Role models the principles of a Just Culture and Organizational Values.
• Must be HIPAA compliant.

Requirements

• One-year recent experience in acute care hospital Utilization Review or equivalent, required.
• Licensed as a Registered Nurse in the state of Colorado or from a valid compact state, required.
• Associate's or Bachelor's degree in nursing, required.
• Must possess, or be able to obtain within 90 days, the computer skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.
• Must have working knowledge of the English language, including reading, writing, and speaking English.

Benefits

• Competitive wages
• Parental leave (4 weeks paid)
• Housing programs
• Childcare reimbursement
• Medical
• Dental
• Vision
• Tuition Assistance
• Existing Student Loan Repayment
• Specialty Certification Reimbursement
• Annual Supplemental Educational Funds
• Up to five weeks paid time off in the first year, increasing with tenure
• 403(b) Retirement plan with immediate matching
• Life insurance
• Short and long-term disability
• Up to $1,000 annual wellbeing reimbursement
• Recreation discounts
• Pet insurance