Insurance Managed Care RN

3 weeks ago

Rock Island Illinois, United States UnityPoint Health Full time
Overview:
Insurance Managed Care RN - Case Manager

Precedence, Inc., Rock Island, IL

Remote or Hybrid with Experience - Based Off Of Location

Full-Time + Benefits

 

 

*Seeking candidate with insurance expereince*

 

The Managed Care RN Utilization/Case Manager, under the direction of the Director of Managed Care serves a key role in coordinating the patient’s/enrollees interdisciplinary providers/services to assess and effectively use resources and to track and minimize the inappropriate use of such resources while providing the right care at the right level at the right time. This role is responsible for utilization management and case management for patients/enrollees. This includes payment authorizations, clinical coordination, integration and facilitation of all care and services for the patient by all members of the health care team.

This role performs admission assessment, continued stay reviews all according to established criteria of third party carriers, and as found necessary on cases with third party payor review. Monitoring of plan of care to address physical and psychosocial needs, and provide problem solving assistance. Coordinates services, discharge planning, referrals to appropriate community agencies and assists with Advance Directives when appropriate. Responsible for reviewing and updating critical paths with healthcare team when applicable.  Also, assessing, monitoring, analyzing and documenting resources utilized in the provision of patient care.

 

 

Why UnityPoint Health? 

Commitment to our Team – For the third consecutive year, we're proud to be recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare for our commitment to our team members. 

Culture – At UnityPoint Health, you matter. Come for a fulfilling career and experience a culture guided by uncompromising values and unwavering belief in doing what's right for the people we serve. 

Benefits – Our competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you’re in. 

Diversity, Equity and Inclusion Commitment – We’re committed to ensuring you have a voice that is heard regardless of role, race, gender, religion, or sexual orientation. 

Development – We believe equipping you with support and development opportunities is an essential part of delivering a remarkable employment experience. 

Community Involvement – Be an essential part of our core purpose—to improve the health of the people and communities we serve. 

 

Visit to hear more from our team members about why UnityPoint Health is a great place to work. 

 

#RYCJessi

Responsibilities:
Performs utilization and case management reviews using established criteria to confirm medical necessity, appropriate level of care and efficient use of resources and payment approval.Applies utilization criteria using designated software to complete documentation related to utilization review activities in an accurate and timely manner for the purpose of providing information for other members of the healthcare team and to facilitate decision making.

Requests reviews with physician advisors, and/or Executive Health Resources (EHR), as appropriate, if admission or continued stay criteria are not met, assuring appropriate and timely level of care status.

Applies accepted potentially avoidable day logic to reviews so that accurate and timely data collection may occur.

Conducts payment authorizations and coordinated payment denials while meeting timeliness guidelines.

Serves as a resource to internal and external staff on issues related to utilization management

Maintains current knowledge of Utilization and Case Review Methodology, software, criteria and regulations governing various payment systems.

Maintains current knowledge of URAC guidelines

Coordinates and monitors appeals internal and with outside organizations used for Second Level Review (e.g. IRO) as needed

Works with physicians regarding utilization issues as needed.

Ensures appropriate discharge/follow up planning

Ensures case coordination with client’s health care providers

Provides utilization management and case management to designated enrollees. Assuring that all enrollees receive clinically sound triage/referral and ongoing care management services for medical needs

Maintains 100% compliance with the laws, standards, rules and regulations of regulatory agencies including but not limited to: URAC, Medicaid, Medicare

Consulting with the medical director/peer reviewer on all high-risk and/or complicated cases, re-admissions and stays over six (6) days

Provides documentation of enrollee contacts and clinical care as it occurs.

Brings any questions or concerns to supervisor for resolution to help facilitate work being meaningful and fulfilling.

Brings a passionate, positive and compassionate attitude to work.

Coordinate the development of patient centered case management.

Qualifications:
Education:

Registered Nurse

Experience:

5+ years of nursing experience

License(s)/Certification(s):

Registered Nurse – Illinois Licensed

Knowledge/Skills/Abilities:

Professional Communication – written & verbal

Customer/patient focused

Self-motivated

Managing priorities/deadlines

Flexibility to adapt to changing priorities or needs

Planning and organizing skills

MS Office proficiency (Outlook, Word)

Ability to give work direction to non-clinical staff

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