Clinical Utilization & Care Manager

Brown Medicine; Los Angeles (CA); Vor Ort; USD 80.000 - 161.000; Vollzeit

Zusammenfassung

Brown University Health seeks an experienced Nurse Manager in Utilization Review to ensure appropriate levels of care, manage third-party authorizations, and lead concurrent reviews. The role collaborates with physicians, reviews Medicare admissions, and guides appeals while improving patient flow and care quality.

The position requires RN licensure (Rhode Island), a nursing degree, and strong analytical skills, with familiarity in InterQual criteria and regulatory guidelines.

Qualifikationen

• RN licensure in Rhode Island per Nursing Compact.
• Five years of clinical experience with utilization review/case management.
• Familiarity with InterQual care management criteria.
• Proficiency with Microsoft Office and scheduling.

Aufgaben

• Oversees medical necessity surveillance of patient care records.
• Applies InterQual level of care screening within one business day of admission.
• Resolves level of care discrepancies with physicians and documents findings.
• Reviews Medicare admissions daily and ensures appropriate care level per guidelines.
• Conducts concurrent reviews every three days to facilitate throughput.
• Delivers HINN notices when inpatient care is not medically necessary and guides appeals.
• Educates healthcare team on Medicare/regulatory guidelines for care levels and appeals.
• Acts with Care Coordination to manage discharge readiness and flow improvements.
• Promotes timely resolution of discharge delays and patient delays.

Kenntnisse

Analytical skills

Interpersonal skills

Collaborative communication

Ausbildung

Bachelor's degree in Nursing

Master’s degree

CPHM certification

Tools

InterQual criteria

Microsoft Office

Jobbeschreibung

Brown University Health seeks an experienced Nurse Manager in Utilization Review to ensure appropriate levels of care, manage third-party authorizations, and lead concurrent reviews. The role collaborates with physicians, reviews Medicare admissions, and guides appeals while improving patient flow and care quality.

The position requires RN licensure (Rhode Island), a nursing degree, and strong analytical skills, with familiarity in InterQual criteria and regulatory guidelines.