Case Manager-2

Southeast Health; Alabama; On-site; USD 70,000 - 90,000; Full time

Job summary

Southeast Health is seeking a Utilization Review Case Manager (RN) to oversee admissions and continued stay reviews in the acute care setting. This role requires strong collaboration with medical staff, timely precertifications, and effective handling of Medicare/Medicaid notifications and denials.

Ideal candidates hold an RN license in Alabama with a track record in discharge planning, utilization review, and clinical leadership.

Qualifications

• Associates degree in Nursing required.
• Active Alabama RN license required.
• Bachelor’s degree in Nursing preferred.

Responsibilities

• Performs admissions and continued stay reviews of inpatients and observation patients.
• Performs precertification on procedures ordered during hospitalization.
• Issues Medicare/Medicaid notifications of medical necessity changes to patients.
• Issues non-coverage letters to patients if needed during stay.
• Documents billing notes in the EMR payer communications navigator to avoid denials.
• Performs medical necessity denial appeals.
• Maintains collaboration with the medical staff to promote continuity of care.

Skills

Nursing knowledge

Discharge planning

Team collaboration

Leadership

Analytical skills

Education

Associates degree in Nursing

Registered Nurse license in Alabama

Bachelor’s degree in Nursing (preferred)

Tools

EMR systems

Job description

## Case Manager-2Apply: SE Health Hospital: Full time: Posted Today: JR15948# **Southeast. Always the right career direction.**## **Job Description Summary**The Utilization Review Nurse screens medical records in accordance with contractual agreement and regulatory requirements for medical necessity on admission and continued stay in the acute care setting. The Utilization Review case manager collaborates with all components of the healthcare system, managing appropriate use of acute care to aid in the achievement of quality outcomes, fiscal responsibility, and patient satisfaction.## **Job Description****Essential Functions*** Performs admissions and continued stay reviews of all inpatients and outpatient/observation patients in a bed; at times, this may be retrospective.* Performs precertification on procedures ordered while patients are hospitalized.* Issues required Medicare/Medicaid notifications of medical necessity changes to patients while hospitalized.* Issues notifications of non-coverage letters to patients if received during hospital stay.* Documents clear billing notes into the Electronic Medical Record (EMR) payer communications navigator to avoid billing denials.* Performs medical necessity denial appeals.* Maintains a close, collaborative relationship with the medical staff to promote continuity of care and avoid delays in service.* Performs other duties as requested by primary manager that do not compromise moral code of conduct or protocols set in place for patient or employee safety### **Supervised Positions*** None**Qualifications**### **Minimum Education Required*** Associates degree in Nursing* Current Registered Nurse license in the State of Alabama### **Minimum Education Preferred*** Bachelor’s degree or higher in Nursing### **Minimum Experience Required*** Two (2) years acute care experience* Must pass Blue Cross Blue Shield Iterator Reliability Test with 90% within six (6) months of hire### **Minimum Experience Preferred*** Three (3) years acute care experience* One (1) year utilization review experience**Required Knowledge/ Skills/ Abilities*** Maintain current licensure in the State of Alabama* Demonstrates appropriate utilization of the skills of the Registered Nurse as approved by the Alabama Board of Nursing* Ability to quickly adapt to changing circumstances in fast-paced environment* Actively accepts, understands, and practices appropriate standards of nursing practice.* Must demonstrate basic knowledge of discharge planning needs* Demonstrates advanced computer skills (ability to generate reports, graph trends).* Clinical knowledge and experience in the care of patients with multiple and complex diagnoses, disease process, and care needs.* Ability to prioritize work and meet deadlines.* Ability to problem solve in a proactive, creative manner, using sound judgment based on factual information and clinical knowledge.* Ability to develop leadership skills and to serve as a role model for clinical staff.* Ability to lead and actively participate in multidisciplinary teams.* Ability to work independently within a team structure.* Demonstrates responsibility for educational requirements as evidenced by reading all assigned related references, and attending all required educational meetings, or webinars, and completing annual Symplr requirements.* Demonstrates commitment to organizations five (5) priorities and Six Ground Rules* Person in this position is required to understand, agree upon and follow our Six Ground Rules: + No excuses. + We are a team. + Bring up your ideas. + Poor performance will be addressed. + ‘That’s not my job’ is not acceptable + Manage Up.## **Shift**Day## Shift Details8:00 am - 4:30 pm## **FTE**1## **Type**Regular## *Join one of Forbes 500 best mid-sized employers in America.*## ***Equal Employment Employer***## *Southeast Health is committed to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, Southeast Health will provide reasonable accommodations for qualified individuals with disabilities.*