The Utilization Review RN Case Manager will collaborate to ensure high-quality care and cost-effective outcomes that promote the physical, psychosocial, and vocational health of plan participants. This role adheres to industry standards and organizational policies set by a leading healthcare management firm.
Daily Responsibilities
Conduct comprehensive utilization reviews, including inpatient and outpatient assessments, admission and discharge planning, retrospective reviews, and readmission evaluations.
Identify and communicate potential large claims, develop quality improvement initiatives, and implement protocols under the direction of the Utilization Review Supervisor.
Facilitate effective communication with large case and disease management teams, as well as payers, ensuring adherence to URAC standards and LHCM documentation requirements.
Manage attending physician statements and provide outstanding customer service to internal and external stakeholders.
Maintain timely documentation, respond to inquiries promptly, and support the Utilization Review Supervisor and LHCM team as needed.
Additional Responsibilities
Complete LHCM Orientation and Training, including familiarity with policies, URAC UM Standards, and clinical review guidelines.
Supervise non-clinical administrative staff involved in UR functions and utilize LHCM-provided software and resources for daily tasks.
Uphold confidentiality standards and participate in ongoing training to enhance skills and knowledge.
Ensure care or services meet initial clinical review criteria; refer cases not meeting criteria to peer clinical reviewers.
Qualifications
Registered Nurse with at least 5 years of recent clinical nursing experience.
Bachelor's Degree and/or Certification in UR, Case Management, or related field preferred.
Strong written and verbal communication skills.
Positive, proactive team-oriented attitude.
Proficiency in computer skills.
Active, unrestricted RN license in a U.S. state or territory.
Other Details
Work Hours: Monday to Friday, 9am-6pm EST (with one late day per month, 10am-7pm EST).
Remote position with occasional compensated on-call responsibilities.
Required in-person training in downtown Nashville for one week.
Holiday shifts required twice a year with holiday pay.
Preferred: Experience in oncology.
Employment Type: Full-Time
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Health Care Provider
Industries
Human Resources Services
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