CA Utilization Review Case Manager I

Ultipro; Rancho Cucamonga (CA); Remote; USD 85,000 - 110,000; Full time

Job summary

CorVel seeks an experienced Utilization Review Case Manager to gather demographic and clinical information for inpatient and outpatient treatments, certify medical necessity, and assign length of stay to support the Case Management department.

This remote position requires RN licensure and strong knowledge of CPT/ICD coding, with 4+ years of clinical experience and UR expertise. Collaboration with claims staff, physicians, and clients is essential.

Qualifications

• Graduate of an accredited school of nursing with an associate’s degree or BSN.
• Current Nursing license in the state of operation; RN is required unless local state regulations permit LVN/LPN.
• 4 or more years of recent clinical experience.
• Prospective, concurrent, and retrospective utilization review experience preferred.
• Experience in OR, ICU, CCU, ER and/or orthopedics preferred.

Responsibilities

• Identifies the necessity of the review process and communicates issues of concern to the appropriate claims staff/customer.
• Collects data and analyzes information to make decisions regarding certification or denial of treatment.
• Documents all work in the appropriate manner.
• Promotes utilization review services with stakeholders.
• Complies with safety rules and regulations during work hours in conjunction with IIPP.
• Additional duties as assigned.

Skills

CPT coding

ICD coding

Interpersonal skills

Time management

Communication

Teamwork

MS Office

Excel

Workers' comp knowledge

Outpatient utilization review

Education

RN license

Nursing degree (ADN/BSN)

Job description

The Utilization Review Case Manager gathers demographic and clinical information on prospective, concurrent and retrospective in-patient admissions and out-patient treatment, certifies the medical necessity and assigns an appropriate length of stay while supporting the goals of the Case Management department and of CorVel.

This is a remote position.

ESSENTIAL FUNCTIONS & RESPONSIBILITIES:

• Identifies the necessity of the review process and communicates issues of concern to the appropriate claims staff/customer
• Collects data and analyzes information to make decisions regarding certification or denial of treatment
• Documents all work in the appropriate manner
• Promotes utilization review services with stakeholders
• Complies with all safety rules and regulations during work hours in conjunction with the Injury and Illness Prevention Program (IIPP)
• Additional duties as assigned

KNOWLEDGE & SKILLS:

• Must have thorough knowledge of both CPT and ICD coding
• Ability to interface with claims staff, attorneys, physicians and their representatives, as well as advisors/clients and coworkers
• Effectiveorganization skills in a high-volume, fast-paced environment
• Strong time management skills with the ability to meet designated deadlines
• Excellent written and verbal communication skills
• Ability to work both independently and within a team environment
• Strong interpersonal skills
• Ability to utilizeMicrosoft Office including Excel spreadsheets
• Knowledge of the workers’ compensation claims process preferred
• Knowledge of outpatient utilization review preferred

EDUCATION & EXPERIENCE:

• Graduate of accredited school of nursing with an associate’s degree,Bachelor of Science degree or Bachelor of Science in Nursing
• Current Nursing licensure in the state of operation required;RN is required unless local state regulations permit LVN/LPN
• 4 or more years of recent clinical experience
• Prospective, concurrent, and retrospective utilization review experience preferred
• Experience in the clinical areas of OR, ICU, CCU, ER and/or orthopedics preferred

PAY RANGE

CorVel uses a market-based approach to pay and our salary ranges may vary depending on your location. Pay rates are established taking into account the following factors: federal, state, and local minimum wage requirements, the geographic location differential, job-related skills, experience, qualifications, internal employee equity, and market conditions. Our ranges may be modified at any time.

For leveled roles (I, II, III, Senior, Lead, etc.) new hires may be slotted into a different level, either up or down, based on assessment during interview process taking into consideration experience, qualifications, and overall fit for the role. The level may impact the salary range and these adjustments would be clarified during the offer process.

In general, our opportunities will be posted for up to 1 year from date of posting, or until we have selected candidate(s) to fulfill the opening, whichever comes first.

ABOUT CORVEL

CorVel, a certified Great Place to Work® Company, is a national provider of industry-leading risk management solutions for the workers’ compensation, auto, health and disability management industries. CorVel was founded in 1987 and has been publicly traded on the NASDAQ stock exchange since 1991. Our continual investment in human capital and technology enable us to deliver the most innovative and integrated solutions to our clients. We are a stable and growing company with a strong, supportive culture and plenty of career advancement opportunities. Over 4,000 people working across the United States embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!).

A comprehensive benefits package is available for full-time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off.

CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.