RN Case Manager - Utilization Review
Healthcare Outcomes Performance Co. (HOPCo)•Phoenix, AZ
•Onsite
About The Position
At The CORE Institute, we are dedicated to taking care of you so you can take care of business! This role involves leadership and advocacy in coordinating patient-centered care across the continuum to facilitate optimal transitions and progression in care. The Case Manager/Utilization Review Nurse works in collaboration with patients/families, physicians, and the interdisciplinary team.
Requirements
- Associate Degree in Nursing (ADN) required
- Three to five years of clinical experience in a direct patient care setting within an acute care hospital required.
- Previous experience in case management or utilization management required.
- A current and unrestricted Arizona Registered Nurse (RN) license.
Nice To Haves
- Bachelor of Science in Nursing (BSN) preferred.
- Certification in Health Care Quality and Management (HCQM) or as a Certified Case Manager (CCM) credential preferred.
Responsibilities
- Conduct concurrent and retrospective reviews of patient medical records to verify the medical necessity of services provided.
- Assess admission criteria and length of stay, applying standardized clinical guidelines such as InterQual or MCG to justify care levels.
- Issue pre-authorizations for procedures, medications, and durable medical equipment by providing clinical information to insurance carriers.
- Collaborate with physicians and other healthcare providers to discuss patient care plans and ensure alignment with coverage policies.
- Facilitate communication between medical staff and payers to resolve issues related to treatment plans and reimbursement.
- Identify and refer cases to case management or social work for complex discharge planning needs.
- Prepare and submit clinical appeals to insurance companies when services are denied, providing documentation to support medical necessity.
- Track and analyze utilization data to identify trends in resource use, care delays, and claim denials for reporting purposes.
Benefits
- Competitive Health & Welfare Benefits
- Monthly $43 stipend to use toward ancillary benefits
- HSA with qualifying HDHP plans with company match
- 401k plan with company match (Part-time employees included)
- Employee Assistance Program that is available 24/7 to provide support
- Employee Appreciation Days
- Free Lunch Fridays
- Closed Holidays
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
