Clinical Utilization Manager

2 weeks ago


Shreveport, Louisiana, United States Specialists Hospital Shreveport Full time
Job 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 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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