Utilization Management Nurse RN

Signature Consulting Services LLC; Louisville (KY); On-site; USD 75,000 - 82,000; Full time

Benefits offered by this job

Medical, dental, vision

Telemedicine

401(k) plan

Tuition reimbursement

Paid Time Off

Life/Disability insurance

Employee discounts

HEART program

Other insurances

Job summary

Signature HealthCARE in Louisville, KY is hiring a Registered Nurse Case Manager to coordinate resident care with MCOs, authorize services, and manage transitions.

Minimum 3 years of case management and hospital/SNF experience required; ACMA/CCMC certification preferred or obtainable after one year. Excellent collaboration and documentation skills are essential.

Qualifications

• RN in good standing with current state license.
• Associates degree required; Bachelor's degree preferred.
• Basic knowledge of medical necessity criteria (Milliman/InterQual).
• Minimum of three years related case management experience.
• Minimum of three years hospital, SNF or Acute Rehab clinical experience.
• Case Management certification (ACMA/CCMC) preferred or willing to obtain.
• Knowledge of Medicare payment methodology and MDS RUG systems.

Responsibilities

• Collaborate regularly with leadership, patients, families and care teams.
• Coordinate internal and external health care team activities for resident care and transitions.
• Conduct baseline assessment of resident care needs and communicate with MCOs.
• Verify care needs and service authorizations and identify outliers.
• Communicate with the MCO at required intervals per contract.
• Negotiate appropriate levels based on services and contracts.
• Document all authorizations and continued stay activity in Case Management software.
• Prepare all Managed Care documentation for facility billing.

Skills

Case management coordination

Communication skills

Medicare/MDS knowledge

Education

RN license

Associate degree required

Bachelor’s degree preferred

Job description

Signature HealthCARE is a family-based healthcare company offering integrated services across multiple states. Our continuum of care includes skilled nursing, rehabilitation, assisted and memory care, and home-based services supported by innovative technologies like telehealth and Care.ai-enabled solutions.

We are committed to advancing person-directed care and quality outcomes. Many of our facilities continue to receive high performance ratings and accreditations. As an award-winning organization recognized over the years by national outlets such as U.S. News & World Report, we take pride in fostering compassionate care environments and being an employer of choice in the healthcare industry.

Overview

Collaboration with Managed Care Organizations (MCO) and care providers is vital to ensure care is being delivered in the right setting at the right time.

How you Will make a difference

• Collaborate regularly and maintain open communication with leadership, patients, families, internal care givers, and external Utilization Management Nurses.
• Coordinate internal and external health care team activities related to resident care, transitions and discharge planning with agencies, and other healthcare organizations.
• Conduct initial baseline assessment of resident care needs and communicate that effectively to the Managed Care Organization (MCO) ensuring all aspects of care services are communicated accurately.
• Verify all care needs and the authorization for services and outliers.
• Communicate/collaborate with the Managed Care Organization (MCO) at required intervals as determined by the MCO
• Negotiate appropriate levels based on services provided and contractual arrangements with the facility and the MCO.
• Document all authorizations and continued stay activity in Case Management software to ensure appropriate reporting and billing
• Prepare all Managed Care documentation to facility accurate billing.

What you Need to make a Difference

• Registered Nurse (RN) in good standing with required current state license.
• Associates degree required, but Bachelor’s degree preferred.
• Basic knowledge of medical necessity criteria such as Milliman Care Guidelines or Interqual.
• Minimum of three (3) years related case management experience.
• Minimum of three (3) years of hospital, SNF or Acute Rehab clinical experience
• Certified in Case Management through ACMA, CCMC or other credentialed agencies, preferred or willing to obtain after one year of employment.
• Knowledge of Medicare payment methodology and the MDS RUG system. Previous experience with MDS and assessment preferred

Our exceptional Benefits Package and Signature Perks include the following and more!

• Medical, Dental and Vision – Voluntary Life/Disability
• Free Telemedicine with Medical Plan
• 401(K) and Roth 401(K)
• Tuition Forgiveness/Education Reimbursement
• A variety of additional specialized Insurances
• Pay Advance and Next Day Pay!
• Paid Time Off (PTO)
• Partner Perks and Discounts!
• Reward & Recognition Program (HEART)
• Vital Links

At Signature HealthCARE, our team members are permitted – no, encouraged – to employ their talents and abilities to solve problems.
Our culture is built on three distinct pillars: Learning, Spirituality and Intra-preneurship.
Each pillar has its own staff and initiatives, ensuring that our unique culture permeates the entire organization.
Come see what the revolution is all about!

Signature HealthCARE is an Equal Opportunity-Affirmative Action Employer – Minority / Female / Disability / Veteran and other protected categories

Salary Range

USD $75,000.00 - USD $82,000.00 /Yr.