Current jobs related to Utilization Review Case Manager - Waterbury - Waterbury Hospital

  • Clinical Case Manager

    7 days ago

    Waterbury, Connecticut, United States Waterbury Hospital Full time

    Job SummaryWe are seeking a skilled Clinical Case Manager to join our team at Waterbury Hospital. The successful candidate will provide clinically-based case management to support the delivery of effective and efficient patient care.Key ResponsibilitiesCollaborate with healthcare team members to identify appropriate utilization of resources and ensure...

  • Clinical Case Manager

    2 weeks ago

    Waterbury, Connecticut, United States Waterbury Hospital Full time

    Job SummaryWe are seeking a highly skilled and experienced Clinical Case Manager to join our team at Waterbury Hospital. As a key member of our Utilization Management department, you will play a critical role in ensuring the delivery of effective and efficient patient care.Key ResponsibilitiesAssess patients for appropriateness of diagnostic testing,...

  • Medical Case Manager

    4 weeks ago

    Waterbury, Connecticut, United States Crawford & Company Full time

    Job SummaryCrawford & Company is seeking a highly skilled Medical Case Manager to join our team. As a Medical Case Manager, you will play a critical role in providing effective case management services to patients/employees who are receiving benefits under an Insurance Line, including Workers' Compensation, Group Health, Liability, Disability, and Care...

  • Social Worker Case Manager

    2 weeks ago

    Waterbury, Connecticut, United States Trinity Health Full time

    Job Title: Social Worker Case ManagementTrinity Health is seeking a skilled Social Worker to join our Case Management team at Saint Mary's Hospital. As a key member of our team, you will be responsible for providing direct Social Work services and interventions to patients and families in the hospital setting.Key Responsibilities:Assess patient needs and...

  • Social Worker Case Manager

    2 weeks ago

    Waterbury, Connecticut, United States Trinity Health Full time

    Case Management Social WorkerTrinity Health is seeking a skilled Case Management Social Worker to join our team at Saint Mary's Hospital. As a Case Management Social Worker, you will play a vital role in assessing and providing direct Social Work services and interventions to patients and families in the hospital setting.Key Responsibilities:Provide ongoing...

  • Case Manager

    3 weeks ago

    Waterbury, United States Wheeler Clinic Full time

    Case Manager Waterbury, CT, USA Req #1587 Friday, October 11, 2024 Wheeler's vision is that all people will have the opportunity to grow, change and live healthier, productive lives. Our mission is to provide equitable access to innovative care that improves health, recovery and growth at all stages of life. POSITION SUMMARY The Senior Counselor...

  • Social Worker Case Management

    6 days ago

    Waterbury, United States Trinity Health Full time

    Employment Type: Part timeShift: Day Shift Description: Saint Mary's Hospital is looking for LCSW / LMSW Social Worker to join our Case Management team. The Social Worker is responsible for assessing and providing direct Social Work services and interventions to patients and families in the hospital setting upon admission and throughout discharge. You Will...

  • Permanent Supportive Housing Case Manager

    2 weeks ago

    Waterbury, Vermont, United States State of Vermont Full time

    Job Summary The State of Vermont is seeking a skilled Permanent Supportive Housing Case Manager to join our team. As a key member of our team, you will be responsible for providing case management services to participants in the State's new Permanent Supportive Housing Medicaid Program. This includes assessing and determining eligibility, developing and...

  • Case Manager, Adult Residential Services Professional

    3 days ago

    Waterbury, Connecticut, United States Community Solutions Full time

    Company Overview:Community Solutions is a nonprofit organization dedicated to promoting responsible citizenship, accountability, and well-being among individuals and families involved in the child welfare, juvenile justice, or criminal justice system. With a rich history dating back to 1962, the organization has been a pioneer in community-based services,...

  • Bilingual Case Manager

    2 weeks ago

    Waterbury, Connecticut, United States Wheeler Clinic Full time

    Job Title: Bilingual Case ManagerWe are seeking a highly skilled and compassionate Bilingual Case Manager to join our team at Wheeler Clinic. As a Bilingual Case Manager, you will provide direct services and case management to families, assisting them in accessing needed supports and resources in the community.Job Summary:The Bilingual Case Manager will work...

  • Case Manager

    2 weeks ago

    Waterbury, Connecticut, United States Wheeler Clinic Full time

    Job Title: Senior CounselorJob Summary:The Senior Counselor provides direct services and case management to families, assisting in accessing needed supports and resources in the community. This role involves facilitating ongoing communication and advocacy, as well as facilitating/co-facilitating groups in accordance with model practice...

  • Case Manager

    2 weeks ago

    Waterbury, Connecticut, United States Wheeler Clinic Full time

    Senior Counselor PositionWheeler Clinic is seeking a highly skilled and compassionate Senior Counselor to join our team. As a Senior Counselor, you will provide direct services and case management to families, ensuring they receive the necessary support and resources to thrive.Key Responsibilities:Develop and implement case management plans to meet the...

  • Case Manager, Adult Residential Professional

    3 days ago

    Waterbury, Connecticut, United States Community Solutions Full time

    Community Solutions is a nonprofit organization that promotes responsible citizenship, accountability, and well-being of individuals and families involved in the child welfare, juvenile justice, or criminal justice system.We deliver supervision, treatment, and comprehensive individualized services to help clients interact effectively in their communities and...

  • Permanent Supportive Housing Case Manager

    2 weeks ago

    Waterbury, Connecticut, United States State of Vermont Full time

    Job Title: Permanent Supportive Housing Case ManagerOverviewThe State of Vermont is seeking a skilled and compassionate Permanent Supportive Housing Case Manager to join our team. As a key member of our team, you will play a vital role in providing case management services for the State's new Permanent Supportive Housing Medicaid Program.Key...

  • Permanent Supportive Housing Case Manager

    2 weeks ago

    Waterbury, Vermont, United States State of Vermont Full time

    Job SummaryThe State of Vermont is seeking a skilled Permanent Supportive Housing Case Manager to join our team. As a key member of our team, you will be responsible for providing case management services to participants in the State's new Permanent Supportive Housing Medicaid Program. This includes assessing and determining eligibility, developing and...

  • Permanent Supportive Housing Case Manager

    2 weeks ago

    Waterbury, Vermont, United States State of Vermont Full time

    Job SummaryThe State of Vermont is seeking a skilled Permanent Supportive Housing Case Manager to join our team. As a key member of our dynamic team, you will play a critical role in providing case management services for the State's new Permanent Supportive Housing Medicaid Program.Key Responsibilities:Determine eligibility for program services and conduct...

  • Therapist Assistant

    1 week ago

    Waterbury, Connecticut, United States CJR Full time

    Job SummaryThe Therapist Assistant will provide case management services to MDFT clients, establishing trusting relationships with family members through home visits, phone contacts, and crisis support. Key responsibilities include:Providing case management services from a strength-based perspectiveCollaborating with MDFT Therapists to develop effective...

  • RN Visiting Nurse Case Manager at Masonicare

    5 days ago

    Waterbury, United States DirectEmployers Full time

    RN Visiting Nurse Case Manager Job Location: Waterbury, Connecticut RN Visiting Nurse Case ManagerMasonicare Home Health & Hospice - Waterbury, CT areaDay Shift / 40hrs/wkMasonicare Home Health & Hospice, an affiliate of Masonicare, is seeking a dedicated and accomplished Registered Nurse Case Manager local to Waterbury, CT area.The RN Visting Nurse Case...

  • Utility Industry Expert

    3 weeks ago

    Waterbury, Connecticut, United States Vermont Public Power Supply Authority Full time

    **Job Summary**The Vermont Public Power Supply Authority is seeking a highly skilled Regulatory and Support Analyst to join our team. This position is responsible for performing analytical work primarily relating to rate, cost-of-service and regulatory activities, financial planning, Integrated Resource Planning and project management.**Key...

  • Business Manager

    1 month ago

    Waterbury, United States Creative Financial Staffing Full time

    Business Manager Comprehensive benefits, including 8-9% profit sharing. Tuition discounts. Employee-focused activities during the summer. Mission-driven organization that has been around for over 70 years. Annual merit increases. Responsibilities of Business Manager: Assist and oversee all functions of the Administrative Support Ensure proper front...

Utilization Review Case Manager

3 months ago

Waterbury, United States Waterbury Hospital Full time
SCOPE OF POSITION:

The Utilization Review Case Manager (UR CM) works in collaboration with the physician and interdisciplinary team to support the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payers. The role integrates and coordinates utilization management and denial prevention by focusing on identifying and removing unnecessary and redundant care, promoting clinical best practice, and ensuring all patients receive "the right care, at the right time, and in the right setting". The UR CM is responsible for preoperative, concurrent, and retrospective reviews in accordance with the utilization management plan. The UM CM ensures the appropriate status and level of care is determined and ensures accurate assessment of medical necessity, thus appropriate reimbursement. Performs duties in support of ECHN mission to ensure the highest quality of patient care in an economically sound and efficient manner.

RESPONSIBILITIES:
  • Conducts concurrent and retrospective review(s) utilizing InterQual (IQ), Milliman Care Guidelines (MCG), or in accordance with CMS rules and regulations for medical necessity criteria to monitor appropriateness of admissions and continued stays, and documents findings based on department policy/procedure; refers appropriate cases to Physician Advisor for recommendation(s).
  • Ensures order in chart/EMR and status coincides with the IQ or MCG review or CMS rules and regulations for appropriate Level of Care and status on all patients through collaboration with Case Manager.
  • Demonstrates thorough knowledge in the application of medical necessity criteria.
  • Assess the safest and most efficient care level based on severity of illness, comorbidities and complications, and the intensity of services being delivered.
  • Utilizes appropriate payer criteria to provide recommendation(s) to the attending physician
  • Communicates payor criteria and issues on a case-by-case basis with multidisciplinary team and follows up to resolve problems with payors as needed; initiates peer to peer when appropriate.
  • Contacts the attending physician for additional information if the patient does not meet the appropriate medical necessity criteria or in accordance with CMS rules and regulations for continued stay.
  • Escalates reviews timely to physician advisor timely for lack of medical necessity and/or status discrepancies.
  • Educates physicians and interdisciplinary team regarding approved criteria practice guidelines, level of care, length of stay, and alternative treatment options.
  • Supports multi-disciplinary strategies to reduce length of stay, reduce resource consumption, and achieve positive patient outcomes.
  • Collaborates with multidisciplinary team members to identify and implement strategies to ensure appropriate utilization and achieve positive patient outcomes.
  • Demonstrates knowledge of target length of stay and GMLOS for diagnosis by actively monitoring length of stay timeframe and implementing measures to achieve targets.
  • Prevents denials by providing timely clinical reviews to payers for authorization of services provided and completes case review for claim reimbursement.
  • Reviews outlier cases to determine level of care and clinical appropriateness.
  • Assists as appropriate in the collection and reporting of financial indicators including length of stay, approved, denied, and avoidable days, and resource utilization.
  • Demonstrates skill in communicating with physicians the necessary documentation to demonstrate medical necessity.
  • Utilizes data to drive decisions related to utilization management for assigned patients, including fiscal and clinical data.
  • Responsible for yearly re-education on industry standard criteria, i.e., InterQual/Milliman Care Guidelines.
  • Collects and analyzes data to provide information regarding system barriers to care delivery, patient care outcomes, resource trends and patterns.
  • Advocates for, supports and protects the rights of patients. Promptly reports any potential compromise of rights to appropriate individual (s).
  • Identifies quality, infection control, utilization, and risk management issues with referrals to appropriate committee/personnel.
  • Continuously pursue excellence in meeting the needs and expectation of all customers (patients, families, inter-disciplinary team members, payors, screener, liaisons and outside services and agencies.
  • Performs all other duties as assigned.
REQUIREMENTS:
  • Bachelor's Degree in Nursing or a related field.
  • Current licensure as an RN.
  • 2 - 3 years' experience in case management, discharge planning, and/or progression of care in the acute-care setting.
  • Minimum of 1 year Utilization Review experience preferred via industry clinical standards, i.e., InterQual, Milliman Care Guidelines.
COMPETENCIES:
  • Comprehensive knowledge of the health care reimbursement system.
  • Demonstrated skill in creative problem solving, facilitation, collaboration, coordination, and critical thinking.
  • Excellent demonstrated oral, written and communication skills.
  • Proficiency in the use of work processing and spreadsheet application.
  • Working knowledge of healthcare reimbursement and available community resources.
  • Must have strong computer skills and the ability to access internet and other programs applicable to Waterbury Hospital procedures.
  • Perform automated functions that fall within job responsibility.