Utilization Review Manager (Registered Nurse/RN)

Life Care Center of Acton•Acton, MA

1d•Onsite

About The Position

The RN Utilization Review Manager coordinates patient care and services and manages resource utilization for skilled patients based on their clinical needs and care plans. The role promotes quality care through a collaborative process that coordinates, monitors, and evaluates services in accordance with patient needs, applicable laws and regulations, and Life Care standards. The manager works with patients and families, the care team, payers, and external entities to support patient safety, the highest practicable physical, mental, and psychosocial well-being, and safe transitions to the next provider or care setting. The position is in-person and is not eligible for remote work. It reports to the Executive Director (ED) or Director of Nursing (DON). The role may include weekend supervision, work beyond normal hours and on weekends or holidays, and temporary work in other positions as needed. Working conditions include frequent interruptions, contact with patients, associates, visitors, and government personnel, possible interactions with hostile or emotionally upset patients or family members, and possible exposure to falls, equipment burns, odors, infectious waste, and diseases including AIDS and hepatitis B viruses.

Requirements

Nursing diploma, associate's degree, or bachelor's degree in nursing.
Current nursing license or registration in the applicable state; must maintain an active Registered Nurse (RN) license in good standing throughout employment.
Knowledge of medical necessity review guidelines for commercial, Medicare, Medicare Advantage, and Medicaid insurance products.
Expert knowledge in the field of practice and knowledge of nursing practices, procedures, laws, regulations, and guidelines governing nursing functions in a post-acute care facility.
Ability to make independent decisions when circumstances warrant.
Ability to implement and interpret nursing department programs, goals, objectives, policies, and procedures.
Clear, concise, well-organized written communication skills; strong organizational, prioritization, and time-management skills.
Ability to use relevant computer systems to enter and retrieve data.
Ability to maintain professional relationships, confidentiality, and compliance with company policies and the Code of Conduct.
Excellent customer service and a positive attitude toward patients.
Ability to concentrate, use reasoning skills and good judgment, and communicate and function productively within an interdisciplinary team.
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) certification or Board Certification in Nursing Case Management (RN-BC).

Responsibilities

Coordinate patient care and services and manage resource utilization for skilled patients according to clinical needs and care plans.
Coordinate, monitor, and evaluate services to promote quality care and support patient safety, well-being, and safe transitions to the next provider or care setting.
Use insurance criteria and regulations to expedite appropriate resource use and comply 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.
Demonstrate effective use of relevant computer systems, including entering and retrieving data.
Assist in the evacuation of patients.
Maintain dependable, regular attendance and work productively within an interdisciplinary team.