Utilization Review RN-Full-Time

The Job: The Case Management function assesses plans implements coordinates monitors and evaluates the options and services required to meet the client s/patient s health and human services needs for an episode of care and when appropriate in transitioning from the acute inpatient episode. Provides advocacy communication collaboration resource management and education to interdisciplinary team and its respective health plan contracts and in the community. Effective allocation of healthcare resources while encouraging provision of high quality patient care is essential in this role. Is cognizant of regulations and policies of all review organizations relating to billing of the fiscal intermediaries and implements processes and changes to meet the Federal/State regulations.Work Schedule: Full TimeLocation: Community HospitalResponsibilities: Maintain and improve the case management system using ongoing interaction with patients physicians and other health providers to meet designated clinical operational and financial outcomes for aggregate patient populations. Assist physicians patients families staff and payers in providing care for patient populations that is appropriate effective and cost efficient. Coordinates clinical review requests from payer sources to ensure timely reviews and ultimately timely payments to the hospital. Attend and actively participate in all departmental and interdepartmental meetings relative to Case Management/Social Services/Discharge Planning functions. EDUCATION and/or EXPERIENCE:Bachelor s Degree in nursing with at least three (3) years of clinical experience in a hospital setting at least three (3) years of case management experience in a hospital setting and at least two (2) years of Utilization Review experience with knowledge of evidencebased criteria guidelines OR equivalent combination of education and experience. CERTIFICATES/LICENSES:Current unrestricted Registered Nurse license in the State of Colorado (required) Case management certification (preferred) or will obtain within 1 year of employment

Shift: FullTime

Specialty Type: Nursing

Sub Specialties: Care Manager Utilization Review RN

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