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Case Manager
2 months ago
Job Summary:
The Utilization Review Nurse will play a critical role in ensuring that patients receive the most appropriate care by reviewing physician orders, documentation, and test results. Utilizing evidence-based tools and critical thinking skills, this nurse will provide recommendations and guidance to providers to develop a plan of care that is based on medical necessity. This role requires strong communication and organizational skills to effectively manage a high-volume caseload and respond to rapidly changing priorities.
Key Responsibilities:
- Perform admission reviews using MCG/Indicia Care Guidelines to facilitate medical necessity.
- Identify opportunities for performance improvement and communicate them to the healthcare team.
- Monitor patients for medical necessity and take necessary action to include issuing ABNs or HINNs and appropriately document.
- Assist in discharge planning and provide resources and plans from the ED as needed.
- Perform other duties as assigned by supervision.
Requirements:
- Education: RN licensure required (Bachelor's preferred). BLS required.
- Training and Experience: 3-5 years clinical experience required.
- Job Knowledge: Knowledge of Conditions of Participation for Utilization Review, effective problem-solving techniques, and excellent oral and written communication skills.
Essentials:
- Must be able to report to work fit for duty and free of any adverse effects of illegal drugs, medical marijuana, prescription medication, and/or alcohol.
- Must be able to effectively communicate both orally and in writing with other individuals.
- Must be able to work independently, anticipate and organize workflow, prioritize, and follow through on responsibilities.
Physical Demands:
Sitting, standing, walking, and lifting will occur for the majority of the shift. Must be able to lift 20 pounds. Must be able to sit/stand for extended periods of time. Fine motor skills. Visual acuity. Depth perception.