Healthcare Utilization Specialist
2 weeks ago
We are seeking a highly skilled Nurse Case Manager to join our team at Vassar Brothers Medical Center. This is a full-time position, working 40 hours per week, with a salary range of $39.21 - $72.83 per hour.
About the Role:
- This role involves providing clinically-based case management to support the delivery of effective and efficient patient care.
- You will pace cases from physiological and economic perspectives, with overall accountability for utilization management and transition management for patients within your assigned caseload.
- You will partner with Social Workers and collaborate with other healthcare team members to identify appropriate utilization of resources and ensure reimbursement.
- You will utilize criteria to confirm medical necessity for admission and continued stay, and create discharge plans appropriate to the patient's needs and resources.
Key Responsibilities:
- Determine medical necessity, appropriateness of admission, continuing stay, and level of care using a combination of clinical information, clinical criteria, and third-party information.
- Validate admission and continuing stay criteria with third-party payers and primary care and attending physicians, recommending alternative care sites where appropriate.
- Collaborate with physician advisors to interface with physicians as needed, and with third-party payers to anticipate denial of payment and proactively address issues contributing to a potential denial.
- Serve as the lead in obtaining financial and other resources for patients/families in need, assess the patient and family for continuing care needs, and develop, implement, and evaluate an effective discharge plan in collaboration with the multidisciplinary team.
Requirements:
- A minimum of 3 years of experience in acute care, preferably in utilization review/management.
- An Associate's Degree or BSN preferred, with a current RN license.
- Strong interpersonal and communication skills, with the ability to form positive, collaborative relationships with hospital staff, patients, and families.
- The ability to work independently, prioritize work, and manage multiple priorities, with analytical abilities to assist in obtaining solutions to problems.
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