RN Case Manager - Utilization Management - Part Time

Augusta Health Careers•Fishersville, VA

5d•Onsite

About The Position

The Utilization Review RN Case Manager applies knowledge of medical necessity criteria and regulatory requirements in determining the appropriate patient status for any person destined for a bed on the patient care units. This position works closely with admitting and attending providers as well as the Utilization Management Physician Advisor to ensure patient status is accurate and compliant with regulatory standards. The Utilization Review RN Case Manager is viewed by clinical teams as an expert in the building when it comes to selecting the appropriate level of service for patients. They participate in multidisciplinary discharge rounds on the hospital units to understand clinical course, discharge plans and possible changes in medical necessity, all toward selecting the levels of care that match clinical necessity. This position plays an essential role in securing reimbursement to the hospital for services provided by commercial, Medicaid and Medicare payers through timely communication and submission of relevant clinical information to the payer when required. The effective tending of utilization review lowers the frequency of avoidable denials by payers for services provided. This role ensures adherence to the policies and guidelines of all payer review organizations to secure appropriate reimbursement for patient hospitalizations. During normal business hours this position may screen patients to determine if case management follow-up is required.

Requirements

Bachelor of Science in Nursing OR Associate’s degree in Nursing PLUS three years of experience as an RN
Registered nurse license in the Commonwealth of Virginia or from a state that is part of a compact agreement with Virginia
Acute care hospital experience or comparable job-related experience in at least 3 of the last 5 years
Comprehensive knowledge of regulatory, legislative, and DNV standards related to utilization review.
Proficient in computer skills including navigating EHRs, medical necessity criteria, Microsoft Office products.
Effective verbal and written skills with the ability to collaborate with multiple disciplines throughout the organization.
Good problem solving and decision-making skills.
Excellent organizational skills and the ability to work in a fast-paced environment.

Nice To Haves

National certification in case management or utilization management preferred
3 to 5 years of recent experience in utilization review and/or discharge planning in an acute care setting preferred

Responsibilities

Determine the appropriate patient status for patients destined for patient care units based on medical necessity criteria and regulatory requirements.
Collaborate with admitting and attending providers and the Utilization Management Physician Advisor to ensure accurate and compliant patient status.
Participate in multidisciplinary discharge rounds to understand clinical course, discharge plans, and changes in medical necessity.
Secure reimbursement for services provided by commercial, Medicaid, and Medicare payers by communicating and submitting relevant clinical information.
Minimize avoidable denials by payers for services provided.
Ensure adherence to policies and guidelines of all payer review organizations for appropriate reimbursement.
Screen patients during normal business hours to determine if case management follow-up is required.