Clinical Utilization Manager
2 weeks ago
The Clinical Utilization Manager coordinates the care plan for assigned members and conducts pre-certification, concurrent review, discharge planning, and case management as assigned. This role ensures efficient utilization of health services and optimal health outcomes for members, as well as meeting designated quality metrics.
Key Responsibilities:
Perform risk-identification, preadmission, concurrent, and retrospective reviews to evaluate the appropriateness and medical necessity of treatments and service utilizations based on clinical documentation, regulatory, and InterQual
Ensure care delivered in a fiscally responsible manner
Report exceptions and variances to the Quality Committee and/or responsible staff
Make informed recommendations as to Level of Care, Length of Stay, and documentation for medical necessity is appropriate
Ensure payer requirements met to insure payment for services rendered. Assist in denial appeals as needed. Monitor insurance for payment/care trends and patterns and refer to appropriate staff
Requirements:
Associate or Bachelor's Degree in Nursing. Current state RN licensure
5 years Utilization Review experience preferred
Experience in a fast-paced environment; orthopedic and spine experience strongly recommended
Benefits:
Seven paid holidays
Sick and vacation after waiting period
Health, vision, and dental coverage
Employer-paid life insurance and long-term disability
401k with employer contribution
Pay in Lieu of Benefits option offered
Specialists Hospital Shreveport is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.
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Clinical Utilization Manager
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Shreveport, Louisiana, United States Specialists Hospital Shreveport, LLC Full timeJob SummarySpecialists Hospital Shreveport, LLC seeks a skilled Clinical Utilization Manager to coordinate care plans for assigned members and conduct pre-certification, concurrent review, discharge planning, and case management as assigned.Key ResponsibilitiesPerform risk-identification, preadmission, concurrent, and retrospective reviews to evaluate the...
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Shreveport, Louisiana, United States Specialists Hospital Shreveport Full timeJob Summary:The Clinical Utilization Manager coordinates the care plan for assigned members and conducts pre-certification, concurrent review, discharge planning, and case management as assigned. This role is responsible for efficient utilization of health services and optimal health outcomes for members, as well as meeting designated quality metrics.Key...
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