RN or LPN - Utilization Manager
About The Position
Under the direction of the Case Management Coordinator, coordinates, negotiates, procures and manages the care of patients to facilitate achievement of positive clinical and financial outcomes. Works collaboratively with interdisciplinary providers internal and external to the organization to coordinate continuing care as appropriate. Participates in performance improvement initiatives related to the management of patient care. Works with physicians to ensure accurate and thorough documentation that will result in correct DRG assignment and improve reimbursement. Performs admissions and continued stay reviews to assure hospitalizations meet payor requirements. Maintains records of review information and outcomes for billing purposes and for compliance with requirements of regulatory agencies and contractual agreements with third party payors. Communicates with multiple individuals for the purpose of obtaining or relaying information regarding the review process. Coordinates the care of patients as they move through the continuum. Coordinates/prepares for retrospective reviews by outside agencies. Reviews the patients' medical record for documentation issues as they relate to the working DRG developed by the Case Manager/Coder. Assists with special projects as directed or requested by the supervisor or department director. Performs Concurrent Review for the presence of history and Physical Exam.
Requirements
- Must be licensed in the State of Alabama, or MSL, as an RN or LPN.
- Three years of clinical experience required.
- Extensive knowledge and understanding of medical terminology and medical science, for effective review of medical records and processes of care.
Nice To Haves
- Leadership experience preferred.
- CM or Utilization Review experience preferred.
Responsibilities
- Coordinates, negotiates, procures and manages the care of patients
- Works collaboratively with interdisciplinary providers internal and external to the organization to coordinate continuing care as appropriate.
- Participates in performance improvement initiatives related to the management of patient care.
- Works with physicians to ensure accurate and thorough documentation that will result in correct DRG assignment and improve reimbursement.
- Performs admissions and continued stay reviews to assure hospitalizations meet payor requirements.
- Maintains records of review information and outcomes for billing purposes and for compliance with requirements of regulatory agencies and contractual agreements with third party payors.
- Communicates with multiple individuals for the purpose of obtaining or relaying information regarding the review process.
- Coordinates the care of patients as they move through the continuum.
- Coordinates/prepares for retrospective reviews by outside agencies.
- Reviews the patients' medical record for documentation issues as they relate to the working DRG developed by the Case Manager/Coder.
- Assists with special projects as directed or requested by the supervisor or department director.
- Performs Concurrent Review for the presence of history and Physical Exam.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Industry
Hospitals
Education Level
No Education Listed
Number of Employees
1,001-5,000 employees
