Case Manager-2

101 Southeast Health; United States; On-site; USD 70,000 - 90,000; Full time

Job summary

Southeast Health in Alabama is seeking an experienced Utilization Review Nurse to screen medical records for medical necessity on admission and during acute care stays. You will collaborate with the medical staff and payer communications to promote appropriate resource use, patient satisfaction, and efficient care delivery.

Requires an Alabama RN license with an Associates degree (Bachelor's preferred); 2 years acute care and UR experience recommended.

Qualifications

• Associates degree in Nursing and current RN license in Alabama.
• Bachelor’s degree or higher preferred.
• Two years acute care experience; three years UR preferred.

Responsibilities

• Screens inpatient and outpatient records for medical necessity during admission and stay.
• Performs precertification on procedures; communicates changes to patients.
• Issues non-coverage letters when applicable and documents billing notes.
• Maintains collaboration with medical staff to ensure timely care.
• Participates in multidisciplinary teams and supports discharge planning.

Skills

Clinical decision making

Team leadership

Discharge planning

Adaptability in fast-paced environment

Education

Associates degree in Nursing

Bachelor’s degree or higher in Nursing

Tools

EMR systems

Report generation

Job description

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

Shift Day Shift Details

8:00 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.

About Southeast Health

Southeast Health is an academic community-based health system serving the healthcare needs of 460,000 residents in southeast Alabama, southwest Georgia, and the Florida panhandle. The organization includes, Southeast Health Medical Center, a 420-bed hospital with the region’s largest medical group and the Alabama College of Osteopathic Medicine (ACOM), the state’s largest medical school. The philanthropic arm of the organization is the Southeast Health Foundation, and its population health division is Southeast Health Statera Network. Southeast Health, a not-for-profit organization, exists to promote healing, prevent disease, educate medicine’s brightest minds, and bring wellness and prosperity to the region it serves. Delivering excellent patient care and top-notch educational experiences begins with great employees, which is why we constantly strive to improve the work experience for our 3,000 team members.