Utilization Review RN, Case Manager

Overview

The Utilization Review RN, Case Manager (full-time, days) collaborates with social workers, case managers, physicians, peers, and third-party payers to facilitate placement of patients in the appropriate level of care related to medical necessity. Responsible for timely provision/flow of specific clinical information to third-party payers to ensure authorization of stay. 

Position Highlights: 

• Shift Schedule:  Full time, Days (Friday-Monday, 8a - 6p)
• Department: Care Coordination - Utilization Review

What You’ll Need:  

• Graduation from accredited School of Nursing; BSN required. MSN preferred.  
• Registered Nurse licensure from the State of North Carolina Board of Nursing 
• Minimum 2 years of relevant clinical experience. Previous Utilization Review experience preferred.  
• Certification in Case Management highly recommended within 2 years of employment.  

Essential Functions:

1. Accurately conducts medical necessity reviews, utilizing the electronic medical record, in accordance with all state and federal regulations and the Utilization Management Plan. Demonstrates proficiency in applying nationally accepted evidence based criteria to assure appropriate hospital level of service.
2. Maintains timely and appropriate documentation of all utilization management activities. 
3. Communicates information effectively, including comprehensive clinical information, to third-party payers, to secure timely authorization for the appropriate level of service. Provides payer feedback to case managers, social workers and providers. 
4. Collaborates with Case Managers and Social Workers to provide information regarding payer criteria and resource availability, and to assist provider team with discharge planning. 
5. Maintains current knowledge of state, federal and commercial payer requirements and guidelines.
6. Communicates with physician advisor and multi-disciplinary care team to ensure appropriate patient status based on medical necessity criteria and level of care. 
7. Collaborates with payer, physician advisor and multi-disciplinary team to reconcile payer-issued denials.
8. Collaborates with physician adviser to identify medical necessity and level of care to ensure appropriate patient status. Communicates physician adviser determination to multidisciplinary team and payers.
9. Understands and maintains application of Medical Center Settings of Care. 
10. Demonstrates knowledge of age/developmentally-appropriate patient care in accordance with Age-Specific Care Guidelines for the specific age groups served.