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Enhances the quality of patient management and satisfaction, to promote continuity of care and cost effectiveness through the integration of functions of case management, utilization review and management, and discharge planning.
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Collaborates with Utilization Review Nurse. Performs patient needs assessments upon admission and at regular intervals; facilitating referrals and providing linkages to health, wellness, and post-acute care resources across the health care continuum.
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Collaborates with Utilization Review regarding insurance concerns and verification of acute and post-acute benefits, manage concurrent denials, and manage patient status changes including observation and code 44.
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Follows patients throughout the continuum of care and ensures optimum utilization of resources, service delivery and compliance with external review agencies. Participates in interdisciplinary patient care rounds and/or conferences to review treatment goals, optimize resource utilization, provide family education and identified post hospital needs.
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Case Manager experience as well as Utilization Review experience (review medical necessity and discharge planning)FLSA Status:Non-ExemptAs a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities.
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JOB SUMMARY: This position is responsible for ensuring accurate and timely clinical review of behavioral health cases for medical necessity including assisting members on the telephone, reviewing medical records, reviewing cases which involves contract interpretation of behavioral health diagnoses, and utilizing knowledge of medical necessity criteria for all levels of behavioral health care from outpatient office visits to acute in-patient to out-patient office visits.
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Coordinates with interdisciplinary care team, physicians, patients, families, post-acute providers, payors, and others in the planning of the patients’ care throughout the care continuum.
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Prefer prior experience in case management, utilization review, or discharge planning. QualificationsEducationGraduate of an accredited program required for RN. BSN preferred; or MSW/BSW with licensure as required by state regulationsLicenses/CertificationHealthcare professional licensure required as Registered Nurse, or Licensed Clinical Social Worker (LCSW) or Licensed Social Worker (LSW) if required by state regulations.
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This Nurse shoud ahve a minimum of 5 years INPATIENT clinical nursing experience in an acute care hospital setting, minimum of 2 years Utilization Management/Review in an acute care setting, Minimum of 2 yeras experience working with InterQual or Milliman in an acute care setting, and Bilingual preferred.
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Minimum Qualifications Possession of (or eligible for) licensure as a Registered Nurse (RN) in Vermont OR eligible to practice in the state of Vermont via a multi-state license AND three (3) years or more of professional nursing experience in an acute hospital setting, long term care, health insurance carrier, or within a community health/public health setting.
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Interim Manager of Case Management ABOUT THE JOB We are looking for a n Interim Manager of Case Management for a 3-6 month assignment with an Acute Care facility in beautiful Dayton, OH. As the Interim Manager of Case Management you will be r esponsible for the day-to-day operations of Case Management Program including utilization review, discharge planning and inpatient denials management.
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Acute care utilization review, discharge planning or case management experience preferred. Utilization Review or other inpatient Case Management certification preferred.
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Utilization Management Conducts medical necessity review for appropriate utilization of services from admission through discharge. QualificationsEducation: Graduate of an accredited program required: RN, BSN preferred ORMaster of Social Work with licensure as required by state regulations; OR Bachelor of Social Work with licensure as required by state regulationsLicenses/Certification:Healthcare professional licensure required as Registered Nurse or Licensed Clinical Social Worker (LCSW) or Licensed Social Worker (LSW) if required by state regulations.
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Additional experience in case management, quality, utilization review, transitional care, or post-acute services is helpful but not required. A registered nurse (RN), with a passion for improving patient care.
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Implements and monitors utilization review process in place to communicate appropriate clinical data to payers to support admission, level of care, length of stay and authorization for post-acute services.
$106,000ExpandApply NowActive JobUpdated 3 days ago
utilization review nurse acute care jobs
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