Utilization Case Manager Coordinator

In this role, the UM, Registered Nurse role is to communicate with payers and provide clinical data to justify patients’ hospital stay. The UM nurse also helps the team understand the Medicare Milliman Clinical Guidelines (MCG) . Other functions like completing PRIs, documenting avoidable delays in care and communicating changes in patients’ medical status contribute to the overall process of discharge planning.

The Utilization Management (UM) department reviews clinical documentation for medical necessity, criteria guided treatment plans and interfaces with the insurance payers to gain financial approval for the hospital stay. The UM department also is involved with denials management in the Peer to Peer process. This process provides information to the insurers while the patient remains in the hospital. This is to facilitate dialogue between the hospital and the insurers in hopes of overturning the denial. The RN UM interfaces with insurance payers. His/her role is to submit pertinent clinical documentation for review, discuss treatment plans with the physicians educate the interdisciplinary team members as to best practice as illustrated by ‘evidenced based’ criteria guidelines.

Requirements: NYS Registered Nurse license, BSN required. Minimum of 1-2 years of clinical experience in nursing; preferably in hospital case management. Experience with InterQual and Milliman Care Guidelines. Knowledge of DRGs and GMLOS , Managed Care and Regulatory Requirements preferred. In addition, knowledge of regulatory guidelines governing hospitals. Medicare, Medicaid, Island Peer Review Organization (IPRO) and other Third Party criteria and standards as applicable.

This is a New York State Nurses Association (NYSNA) Union position. This position requires the employee to work on site. There is no remote ability, for this position

CM/UM Department Goals

Both UM/CM collaborates with healthcare professionals, paraprofessionals, Social Work, Physical therapy etc. to determine correct level of care, disposition and discharge planning.

The goals of the CM/UM department are to decrease LOS (length of stay) in the acute care setting, ensure quality, and cost-effective services to patients. Collaborate with the IDT (interdisciplinary team), to provide the best quality care, determine safe dispositions and discharge plans for patients while advocating for the patient in the acute care setting.

If you meet the required qualifications, please apply today!

Work Location is on-site. There is no option for remote work.

Job Type: Full-time

Pay: From $106,201.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Application Question(s):

• Are you able to work on-site ?
• Do you have direct experience with InterQual and Milliman Care Guidelines as well as knowledge of DRGs and GMLOS ?

Education:

• Bachelor's (Required)

Experience:

• Utilization review: 2 years (Required)

License/Certification:

• RN (Required)

Work Location: In person