Case Manager - Utilization Management

1004 Lehigh Valley Hospital; Pennsylvania; Hybrid; USD 90,000 - 120,000; Full time

Job summary

Lehigh Valley Health Network is seeking an experienced RN for Utilization Management. You will review admissions, determine appropriate patient class, and ensure compliance with third-party payer requirements.

The role requires knowledge of evidence-based criteria and collaboration with precert, services, billing, coding, and finance to optimize reimbursement and patient care in a remote Pennsylvania setting.

Qualifications

• Specialized Diploma in nursing and 2 years of utilization review experience.
• Knowledge of utilization management as it relates to third party payers.
• Ability to maintain the strictest adherence to HIPAA while maintaining confidentiality of all PHI.
• Ability to work in a team environment with prioritized goals and multiple responsibilities.
• RN - Licensed Registered Nurse in PA upon hire; PA licensure required.

Responsibilities

• Acts as a resource and educates on appropriate level of care assignment, patient class, and utilization management.
• Provides timely, accurate clinical reviews to assist patient class decisions.
• Develops and implements methods, policies, and procedures to improve efficiency.
• Partners with unit-based care managers to ensure information exchange on financial status, diagnosis, and discharge needs.
• Works with precert/preservices, appeals, patient access, billing, coding, and finance to complete reviews.
• Completes clinical review and assesses admission appropriateness through evidence-based criteria.
• Collaborates with management and others to facilitate patient class assignments and problem-solving for complex cases.
• Performs patient class change processes as directed by physicians and payers.
• Documents authorizations and downgrades per policy.
• Participates in Performance Improvement to meet FY goals and streamline procedures.

Skills

HIPAA compliance

Team player

Attention to detail

Multitasking

Work queue proficiency

Education

Specialized Diploma in nursing

Bachelor’s Degree in nursing

ACMA - Accredited Case Manager

CCM - Certified Case Manager

ABMCN - Certified Managed Care Nurse

Job description

Imagine a career at one of the nation's most advanced health networks. Be part of an exceptional health care experience. Join the inspired, passionate team at Lehigh Valley Health Network, a nationally recognized, forward-thinking organization offering plenty of opportunity to do great work. LVHN has been ranked among the "Best Hospitals" by U.S. News & World Report for 23 consecutive years. We're a Magnet(tm) Hospital, having been honored five times with the American Nurses Credentialing Center's prestigious distinction for nursing excellence and quality patient outcomes in our Lehigh Valley region. Finally, Lehigh Valley Hospital - Cedar Crest, Lehigh Valley Hospital - Muhlenberg, Lehigh Valley Hospital- Hazleton, and Lehigh Valley Hospital - Pocono each received an 'A' grade on the Hospital Safety Grade from The Leapfrog Group in 2020, the highest grade in patient safety. These recognitions highlight LVHN's commitment to teamwork, compassion, and technology with an unrelenting focus on delivering the best health care possible every day. Whether you're considering your next career move or your first, you should consider Lehigh Valley Health Network.

Summary

Ensures appropriate use of hospital resources by reviewing all patients admitted to the hospital and evaluating appropriateness of admission using approved criteria. Ensures appropriate patient class assignment (inpatient, outpatient) to ensure compliance with third party payer requirements.

Job Duties

• Acts as a resource and educates on the appropriate level of care assignment, patient class, and utilization management-related work.
• Provides timely, accurate, and thorough clinical reviews to assist in the patient class decision-making process.
• Develops and implements methods, policies, and procedures to improve departmental efficiency and overall effectiveness.
• Partners with unit-based care managers to ensure appropriate exchange of information regarding patient financial status, diagnosis, and discharge needs.
• Works closely with precert/preservices, appeals, patient access, billing, coding, and finance to complete all reviews thoroughly and accurately.
• Completes clinical review and assesses the appropriateness of admission through the evaluation of evidence-based criteria.
• Works collaboratively with management, peers, and other colleagues outside of the department to facilitate appropriate patient class assignment, assist in problem-solving with complex cases, and help investigate cases to maximize reimbursement.
• Performs patient class change process in a timely and efficient manner at the direction of the physician advisor, attending provider, and/or in conjunction with the appropriate payer.
• Documents authorizations and downgrades according to departmental policy and procedure.
• Participates in the Performance Improvement process including assessment, implementation, and evaluation of new/updated processes to ensure goals are met each FY, as well as all procedures are streamlined for effectiveness and efficiency.

Minimum Qualifications

• Specialized Diploma in nursing 2 years of previous utilization review experience. and 2 years Knowledge of utilization management as it relates to third party payers.
• Ability to maintain the strictest adherence to HIPAA while maintaining confidentiality of all PHI.
• Ability to work in a team environment demonstrating flexibility to work toward common goals based around prioritized needs.
• Ability to be attentive to detail and maintain a positive attitude.
• Ability to complete work assignments accurately and in a timely manner while managing multiple responsibilities and prioritizing all tasks effectively.
• Demonstrates proficiency with all work queue processes.
• Knowledge of evidence-based clinical decision support criteria.
• RN - Licensed Registered Nurse_PA - State of Pennsylvania Upon Hire
• Preferred Qualifications Bachelor’s Degree In nursing Knowledge of evidence-based criteria such as InterQual criteria and/or MCG criteria.
• ACM - Accredited Case Manager ACMA - State of Pennsylvania Upon Hire
• CCM - Certified Case Manager CCMC - State of Pennsylvania Upon Hire
• CMCN - Certified Managed Care Nurse ABMCN - State of Pennsylvania Upon Hire

Physical Demands

• Lift and carry 7 lbs., continuous sitting >67%, frequent keyboard use/repetitive motion, frequent fine motor activity/wrist position deviation.

Job Description Disclaimer

This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Equal Opportunity Statement

Lehigh Valley Health Network is an equal opportunity employer. In accordance with, and where applicable, in addition to federal, state and local employment regulations, Lehigh Valley Health Network will provide employment opportunities to all persons without regard to race, color, religion, sex, age, national origin, sexual orientation, gender identity, disability or other such protected classes as may be defined by law. All personnel actions and programs will adhere to this policy. Personnel actions and programs include, but are not limited to recruitment, selection, hiring, transfers, promotions, terminations, compensation, benefits, educational programs and/or social activities.

Location and Schedule

Work Shift: Day Shift Address: 1200 S Cedar Crest Blvd Primary Location: REMOTE IN PENNSYLVANIA Position Type: Remote Union: Not Applicable Work Schedule: 8 hours. M-F. Weekend and holiday coverage.

Department

Department: 1004-09392 COH - Utilization Management Lehigh Valley Health Network (LVHN) is the region’s largest employer and health care provider of choice. Our nearly 20,000 health care professionals take pride in what they do and are driven by our mission to heal, comfort and care for the people of our community.

Corporate Culture

LVHN is honored to be certified as a Great Place to Work®. LVHN’s culture of trust – and the positive things colleagues said about working at LVHN when surveyed by Great Place to Work and Fortune – align perfectly with what makes a great workplace. This designation tells you that LVHN is a great place to work from hire to retire. If you are someone who aligns with LVHN’s core values – Compassion, Integrity, Collaboration and Excellence – you will have a rewarding and successful career here.

Video

https://youtu.be/GD67a9hIXUY