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Jordan Hospital RN - Case Manager / Utilization Review in Plymouth, Massachusetts

Duties/Responsibilities:

  • Reviews admission data to establish the appropriate level of care using Interqual criteria.

  • Integrates clinical knowledge with billing knowledge to review, evaluate, and appeal clinical denials related to the care provided to the hospitalized patient.

  • Conducts concurrent reviews to determine the continued need for acute care setting, appropriateness and timeliness of treatments/procedures and to optimize the potential for reimbursement.

  • Collaborates with the multidisciplinary team to assess and improve the denial management, documentation, and appeals process.

  • Collaborates with UR Manager and/or physician advisor regarding cases that do not meet established guidelines for admission or continued stay.

  • Acts as a liaison between physicians and payers, coordinating peer-to-peer phone calls.

  • Collects and compiles data as required.

    It is understood that this is a summary of key job functions and does not include every detail of the job that may reasonably be required.

    Education/Experience Required:

  • Current MA RN licensure

  • Bachelor’s Degree in Nursing or advanced degree in healthcare preferred.

  • Three years recent, broad clinical experience in the hospital setting

  • Experience with utilization management within the last 3 years required

  • An understanding of the severity of an array illnesses, intensity of service, and care coordination needs

  • Ability to identify appropriateness of patients admission and level of care needs (inpatient & observation) utilizing Interqual criteria

  • Knowledge of Interqual required; Allscripts preferred

  • Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with patients, physicians, colleagues and insurance companies

  • Knowledge of government and insurance company reimbursement policies in regards to admission criteria, treatment and length of stay

  • Ability to work independently

    Registration/Certification:

  • Current MA RN licensure

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