Case Manager - Utilization Review Specialist - REMOTE

McKenzie-Willamette Medical Center; Springfield (OR); Remote; USD 60,000 - 80,000; Full time

Job summary

An established industry player in healthcare is seeking a dedicated professional to join their team. This role involves analyzing patient records to ensure compliance with admission and treatment standards, as well as reviewing applications for patient admissions. The ideal candidate will have significant experience in clinical nursing and case management, with a strong understanding of regulatory requirements. This is a fantastic opportunity to contribute to patient care and ensure quality standards are met in a dynamic healthcare environment. If you are passionate about making a difference in patient outcomes, this role is perfect for you.

Qualifications

• Minimum five years as a clinical nurse in an acute care setting.
• Experience in case management and knowledge of payer regulations preferred.

Responsibilities

• Analyze patient records for compliance with admission and treatment standards.
• Review applications for patient admission and approve or refer as necessary.

Skills

Clinical Nursing

Case Management

Discharge Planning

Utilization Review

Regulatory Knowledge

Education

Bachelor's Degree

Current Oregon RN state license

Tools

InterQual Level of Care Criteria

Milliman & Robertson Criteria

Job description

Pay $32.15 - $48.05 / hour

Location: Springfield/Oregon

Employment type: Full-Time

Job Description

• Req#: CASEM027065
• Hourly Base Rate: $32.15 - $48.05
• Shift: Day Shift - Remote
• Hours Per Week: 40-hours
• Date Posted: 6/1/2023

Job Summary:

• Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in health-care facility to comply with government and insurance company reimbursement policies.
• Reviews application for patient admission and approves admission or refers case to facility utilization review committee for review and course of action when case fails to meet admission standards.
• Compares inpatient medical records to established criteria and confers with medical and nursing personnel and other professional staff to determine legitimacy of treatment and length of stay.
• Abstracts data from records and maintains compliance with established standards.

Educational/Licensure:

• Current Oregon RN state license, or current State RN license and ability to obtain OR RN license within 6 months of hire.
• Knowledge in areas such as InterQual Level of Care Criteria and Milliman & Robertson Criteria as well as knowledge of third party payer regulations related to utilization and quality review is also preferred.

Qualifications:

• Significant experience in the healthcare field is required including a minimum of five years as a clinical nurse in an acute care setting.
• At least five to seven years of experience in case management, discharge planning, and/or utilization review is preferred.
• Knowledge of regulatory and payer requirements for Case Management Activities.
• Ability to critically evaluate and make decisions about discharge planning for highly difficult cases.

Education

Preferred:

Bachelor's Degree

Licenses & Certifications

Required:

L-OR-RN License

About the Company

McKenzie-Willamette Medical Center is an acute care hospital located in Springfield, Oregon, United States.