Case Manager - Utilization Management

Lehigh Valley Health Network; United States; Remote; USD 70,000 - 100,000; Full time

Job summary

Lehigh Valley Health Networkis seeking an experienced RN to join the Utilization Management team in a remote role. You will review admissions, determine appropriate patient class, and ensure payer-aligned care decisions using evidence-based criteria.

Responsibilities include educating care teams, documenting authorizations, and collaborating with precert, billing, and finance to optimize reimbursement while maintaining HIPAA compliance.

Qualifications

• RN - Licensed Registered Nurse (PA) Upon Hire.
• 2 years utilization review experience.
• 2 years knowledge of utilization management for third party payers.
• HIPAA confidentiality adherence.
• team-oriented with flexibility to prioritize needs.
• attention to detail and timely work delivery.

Responsibilities

• Review patient admissions to assess appropriateness using approved criteria.
• Educate on appropriate level of care and patient class assignments.
• Provide clinical reviews to support decision-making for payer requirements.
• Develop and improve policies to enhance department efficiency.
• Collaborate with care managers, precert/preservices, and billing teams to ensure accurate reviews.
• Document authorizations and downgrades per policy; participate in Performance Improvement activities.

Education

Specialized Diploma in nursing

Bachelor's Degree in nursing

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 and
• CCM - Certified Case Manager CCMC - State of Pennsylvania Upon Hire and
• 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.

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.

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Lehigh Valley Health Network does not accept unsolicited agency resumes. Agencies should not forward resumes to our job aliases, our employees or any other organization location. Lehigh Valley Health Network is not responsible for any agency fees related to unsolicited resumes.

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

1004-09392 COH - Utilization Management