Case Manager - Utilization Review RN

Under the general direction of the Director of Behavioral Health, the Case Manager – Utilization Review RN provides clinically based case management and utilization review services to support the delivery of high-quality, cost-effective patient care. The RN is responsible for concurrent utilization review, medical necessity determination, denial prevention, discharge planning, care coordination, and resource management across the continuum of care.

The Case Manager – Utilization Review RN collaborates with physicians, interdisciplinary team members, physician advisors, social workers, revenue cycle staff, and third-party payers to ensure appropriate utilization of hospital resources, regulatory compliance, optimal reimbursement, and safe patient transitions.

Community First Medical Center offers benefits to all its full-time and part-time employees:

United Healthcare Medical PPO/HMO/HSA Plans, premiums as low as $50.00/full time, $85.00/Part Time

Met Life Dental and Vision

• Paid Time Off (PTO) with annual accruals up to 168 hrs./year
• Six paid holidays
• Company Paid Life insurance and Short-term Disability
• 401(k) after 90 days
• Continuing Education reimbursement and 2 days paid off separate from PTO
• Free Parking Garage
• Internal Growth Opportunities

Requirements

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Qualifications

• Education
• Associate Degree in Nursing required.
• Bachelor of Science in Nursing (BSN) preferred.

Experience

• Minimum three (3) years of acute care nursing experience required.
• Minimum two (2) years of Case Management and/or Utilization Review experience preferred.
• Experience with discharge planning, utilization review, denial management, and payer authorization preferred.

Licensure

• Current Illinois Registered Nurse license required.
• ACM, CCM, or CMAC certification preferred.

Knowledge, Skills & Abilities

• Knowledge of Medicare, Medicaid, and commercial insurance regulations.
• Working knowledge of InterQual and/or MCG criteria.
• Behavioral Health background knowledge

Access to Behavioral Health Networks

• Understanding of utilization management and care coordination principles.
• Knowledge of discharge planning and post-acute care resources.
• Strong analytical and critical thinking skills.
• Excellent verbal and written communication skills.
• Ability to prioritize multiple complex patient cases.
• Ability to build collaborative relationships with physicians and interdisciplinary teams.
• Computer proficiency and electronic medical record experience.

Performance Expectations

Success in This Role Is Measured By

• Appropriate admission status determination
• Denial prevention and appeal success
• Timely discharge planning
• Reduction in avoidable days
• Average Length of Stay management
• Readmission reduction
• Documentation compliance
• Regulatory compliance
• Patient throughput
• Patient and physician satisfaction