Utilization Review Manager (Registered Nurse/RN) LPN Case manager

Life Care Center of Acton•Acton, MA

6d•Onsite

About The Position

The RN Utilization Review Manager coordinates patient care and services and manages resource utilization for skilled patients according to their clinical needs and care plans. The role promotes quality care through a collaborative process that coordinates, monitors, and evaluates services in accordance with applicable laws, regulations, and Life Care standards. The manager works with patients and families, the care team, payers, and external entities to support patient safety, well-being, and a safe transition to the next provider or care setting. This is an in-person position at 1 Great Rd., Acton, MA 01720, and is not eligible for remote work. The position reports to the Executive Director (ED) or Director of Nursing (DON). Working conditions may include weekend supervision, work beyond normal hours and on weekends or holidays, frequent interruptions, and temporary work in other positions as needed. The role involves contact with patients, associates, visitors, government agencies, and others, including people who may be hostile or emotionally upset, and possible exposure to workplace hazards and infectious materials.

Requirements

Nursing diploma, associate's degree in nursing, or bachelor's degree in nursing.
Current license or registration in the applicable state and an active Registered Nurse (RN) license in good standing throughout employment.
Ability to generate clear, concise, well-organized written communication.
Excellent organizational skills and ability to prioritize and manage time and assignments efficiently.
Knowledge of medical necessity review guidelines for commercial, Medicare, Medicare Advantage, and Medicaid insurance products.
Expert knowledge in the field of practice.
Ability to make independent decisions when circumstances warrant.
Knowledge of nursing practices and procedures and laws, regulations, and guidelines governing nursing functions in a post-acute care facility.
Ability to implement and interpret nursing department programs, goals, objectives, policies, and procedures.
Proficiency in applicable competency areas.
Ability to maintain professional relationships and confidentiality, follow company policies, and complete required compliance training.
Ability to demonstrate efficient use of relevant computer systems, including data entry and retrieval.
Ability to concentrate and use reasoning skills and good judgment.
Ability to read, write, speak, and understand English.
Ability to sit, stand, bend, lift, push, pull, stoop, walk, reach, and move intermittently during working hours.
Ability to lift 35 pounds from floor to waist and waist to shoulder, lift and carry 35 pounds, and push or pull 35 pounds.

Nice To Haves

One year of clinical experience in a post-acute care setting.
Prior case management, utilization review, and discharge planning experience.
Certified Case Manager (CCM) or Board Certification in Nursing Case Management (RN-BC).

Responsibilities

Coordinate patient care and services and manage resource utilization for skilled patients based on their clinical needs and care plans.
Coordinate, monitor, and evaluate services to promote quality care and compliance with applicable laws, regulations, and Life Care standards.
Work with patients, families, the care team, payers, and external entities to support patient safety, well-being, and transitions to the next provider or care setting.
Use insurance criteria and regulations to support appropriate resource use and compliance with third-party payer contracts.
Work closely with the business office manager to obtain, oversee, and communicate certifications, authorizations, payment denials, and notices of non-coverage.
Serve as a liaison to external case managers, families, physicians, and community resources.
Train and educate patients, families, associates, and other care providers.
Implement standards of practice for care management, ethical performance, and coordination of care.
Use relevant computer systems to enter and retrieve data.
Assist in the evacuation of patients.
Communicate and function productively within an interdisciplinary team.
Attend and participate in continuing education programs.
Maintain professional working relationships, confidentiality, and compliance with company policies and training requirements.
Demonstrate dependable, regular attendance and provide excellent customer service with a positive attitude toward patients.