Case Manager-2

Southeast Health; Dothan (AL); On-site; USD 65,000 - 85,000; Full time

Job summary

Southeast Health seeks an Utilization Review Nurse to screen medical records for medical necessity on admission and during hospital stay. You will conduct admissions and continued stay reviews for inpatients and observation patients, handle precertifications, and issue notifications for medical necessity changes and non-coverage letters.

Collaboration with medical staff is essential for timely care. Ideal candidates hold an RN license in Alabama with acute care experience and a background in

Qualifications

• Associates degree in Nursing
• Current RN license in the State of Alabama
• Bachelor’s degree or higher in Nursing (preferred)
• Two (2) years acute care experience (required)
• Three (3) years acute care experience (preferred)
• One (1) year utilization review experience (preferred)
• Maintain licensure and demonstrate ongoing professional development
• Ability to generate reports and use computer systems for documentation

Responsibilities

• Screens medical records for medical necessity upon admission and during stay
• Performs admissions and continued stay reviews for inpatients and observation patients
• Performs precertification on procedures
• Notifies patients of medical necessity changes and non-coverage letters
• Documents payer communications in EMR to avoid denials
• Maintains collaboration with medical staff to promote continuity of care
• Participates in education and may attend required meetings/webinars

Skills

Discharge planning

Multidisciplinary teamwork

Problem solving

Leadership

Clinical judgment

Adaptability

Fast-paced environment

Communication

Education

Associate's degree in Nursing

Bachelor’s degree in Nursing

Job description

Southeast. Always the right career direction.Job Description SummaryThe 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 DescriptionEssential FunctionsPerforms 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 safetySupervised PositionsNoneQualificationsMinimum Education RequiredAssociates degree in NursingCurrent Registered Nurse license in the State of AlabamaMinimum Education PreferredBachelor’s degree or higher in NursingMinimum Experience RequiredTwo (2) years acute care experienceMust pass Blue Cross Blue Shield Iterator Reliability Test with 90% within six (6) months of hireMinimum Experience PreferredThree (3) years acute care experienceOne (1) year utilization review experienceRequired Knowledge/ Skills/ AbilitiesMaintain current licensure in the State of AlabamaDemonstrates appropriate utilization of the skills of the Registered Nurse as approved by the Alabama Board of NursingAbility to quickly adapt to changing circumstances in fast-paced environmentActively accepts, understands, and practices appropriate standards of nursing practice.Must demonstrate basic knowledge of discharge planning needsDemonstrates 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 RulesPerson 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 acceptableManage Up.ShiftDayShift Details8:00 am - 4:30 pmFTE1TypeRegularJoin one of Forbes 500 best mid-sized employers in America.Equal Employment EmployerSoutheast 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.