UTILIZATION REVIEW CASE MANAGER

St. Marys Health System-posted 7 months ago

Full-time • Mid Level

Lewiston, ME

Nursing and Residential Care Facilities

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The UR Case Manager conducts medical necessity reviews per the Utilization Management (UM) plan for patients housed on a nursing unit, including inpatient admissions, patients on observation, and outpatients in a bed. The UR Case Manager identifies delays in care and documents and communicates findings with the care team and the payor, when necessary. The UR case manager also acts as an advocate for the patient and assists in providing information regarding their insurance coverage.

Conduct medical necessity reviews per the Utilization Management (UM) plan.
Identify delays in care and document findings.
Communicate findings with the care team and the payor.
Act as an advocate for the patient.
Provide information regarding patients' insurance coverage.

Bachelor's degree required.
Active State of Maine RN license.
Minimum of three years' experience in utilization review, discharge planning, social work case management, or Utilization Manager experience preferred.
Certification as CCM or ACMA-RN preferred.
Proficient in Microsoft Office.
Strong verbal and written communication skills.
Strong interpersonal skills.
Ability to work within a stressful, fast-moving environment.
Knowledge of community agencies and resources preferred.
Knowledge of third-party payer systems.

Certification as CCM or ACMA-RN preferred.
Knowledge of community agencies and resources preferred.
Knowledge of third-party payer systems.

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