CASE MANAGER FT - Utilization Review

Cullman Regional Medical Center, Inc.; Alabama; On-site; USD 85,000 - 105,000; Full time

Job summary

Cullman Regional Medical Center, Inc. is seeking a Nurse Case Manager to coordinate multidisciplinary care, facilitate precertification, and lead utilization review initiatives. You will work with physicians, nurses, social workers, and other health professionals to ensure cost-effective care and adherence to clinical guidelines.

The role emphasizes leadership in quality improvement, patient safety, and exceptional patient experiences within an acute care setting.

Qualifications

• Associate degree in nursing or higher; Alabama license required.
• Five years of clinical experience in acute care settings (medical-surgical, ICU, ER, OR).
• Experience in Utilization Review is preferred.
• Familiar with CMS Guidelines and navigating payor portals.
• Excellent organizational and communication skills.

Responsibilities

• Coordinate with physicians, nurses, social workers and other health team members to expedite medically appropriate, cost-effective care.
• Support physician provision of patient care with accountability for designated patient caseload.
• Facilitate precertification and payor authorization processes and collaborative management across the continuum.
• Promote effective utilization and monitoring of healthcare resources and adherence to evidence-based guidelines.
• Lead quality improvement activities related to quality measure initiatives and patient safety.
• Demonstrate and encourage teamwork and exceptional patient experiences.

Skills

Advanced communication

Interpersonal skills

Microsoft Word

Excel

CMS guidelines knowledge

Education

Associate degree in nursing (ADN)

BSN preferred

Tools

Payor portals

CMS guidelines

Job description

Job Summary:Coordinate with physicians, nurses, social workers and other health team members to expedite medically appropriate, cost-effective care.Support physician provision of patient care with accountability for designated patient case load.Facilitate precertification and payor authorization processes and facilitate collaborative management of patient care across the continuum, intervening as necessary.Promote effective utilization and monitoring of healthcare resources and assumes a leadership role with the multidisciplinary team to achieve optimal clinical and resource outcomes.Apply process improvement methodologies in evaluating outcomes of care.Maintain and ensure adherence to clinical guidelines, tools and protocols based on evidence-based medicine related to quality measure indicators.Assume leadership role in coordinating quality improvement activities related to quality measure initiatives.Demonstrate and encourage team behavior and exceptional patient/guest experiences.Uphold and promote patient safety and quality.Education:Associate's degree in nursing or higher degree is required. Currently licensed by the state of Alabama. BSN preferred.Experience:Five years' clinical experience in acute care setting i.e., medical surgery, ICU, ER, OR required. Previous Utillization Review experience is preferred.Additional Skills/Abilities:Skill and proficiency in applying highly technical principles, concepts and techniques that are central to case management. Advanced communication and interpersonal skills with all levels of internal and external customers. Must be proficient in Microsoft Word and Excel. Familiar with CMS Guidelines, navigating within payor portals, following up on pending approvals/denials. Excellent organizational skills are required. Must be able to set priorities appropriately and handle multiple issues concurrently.