Case Manager/Utilization Review, RN

4 weeks ago


Raleigh, United States WakeMed Full time

Position Information:


The Nurse Case Manager is a Registered Nurse responsible for providing patient case management services to assigned populations. Utilizes a collaborative interdisciplinary approach to anticipate integrate and coordinate the patient's plan of care discharge plan and re-entry into the community. In collaboration with the treatment team the nurse case manager identifies at risk patient populations who require patient case management services.Provides bio-psychosocial assessments assists patients with self-management skills educational materials advocacy resources and/or support groups so they can be full participants in their treatment and recovery. The nurse case manager serves as a patient/family advocate and acts as a communication link between the physician patient family health care team community resources and payors to reduce redundancy and fragmentation of care. Anticipates potential delays in the health care process and acts pro-actively to avoid these delays. Reviews and assesses appropriateness of patient admission/continued stay. Completes concurrent reviews and monitors the use of insurance benefits to maximize service to patients. Provides timely pertinent insurance benefits information to clinical staff so that they will provide care within patients? benefits package and thereby optimize third party payment for services. Assists physicians in preparing appeals when payment has been denied by insurance companies. Assists in the implementation of the Hospital Utilization Review Plan. Provides consultation and/or education to clinical staff regarding monitoring studies and medical records reviews. Participates in the preparation and tracking of the Involuntary Commitment processes and represents the hospital in involuntary hearings process.

Experience Requirements:
3 Years Nursing - Related Area Required - And 5 Years Nursing - Related Area Preferred In Clinical - Case Management Or Clinical - Discharge Planning Or Accounting/Finance - Third Party Review Or Clinical - Home or Community Health Preferred

Select Education Type:
Graduate Nursing Required - And Bachelor's Degree Required - In Nursing Preferred

Licensure/Certification Requirements:
Registered Nurse Required - And Certified Case Manager Or Commission for Case Management Certification Required - Within 1 Year of Hire And Certified Notary Required - Within 1 Year of Hire

Hours of Work:
Saturday & Sunday, 6:45am-5:15pm

Weekend Requirements:
Every Weekend

Call Requirements:
None


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