Case Mgt Utilization Review RN - REMOTE
The Care Manager assumes primary responsibility for documentation of appropriate medical necessity for the inpatient status or placement in observation. Communicates with the physicians and clinicians. Assures clinical information is sent to the payor timely to complete the authorization of the patient stay. Collaborates and coordinates with other allied health professionals to ensure quality care is provided and desired outcomes are achieved in a timely and cost-effective manner.
- Utilizes a complete and systematic methodology/process to assess, plan, implement, evaluate and provide patient care coordination from pre-hospital through post-hospital care.
- Assists in the development of physician profiles to identify over/under utilization patterns.
- Supports Steward Health Care's and hospital goals and objectives. Works within regulatory compliance guidelines.
- The Care Manager works collaboratively with all healthcare disciplines to assure appropriate and timely services.
- Assesses the medical appropriateness, quality, and cost-effectiveness of proposed hospital, medical, and surgical services.
- Collaborates with the multidisciplinary team to assist patient with benefits management.
- Communicates with payers to obtain authorization.
- Identifies and plans strategies to optimize inpatient length of stay and resource utilization.
REQUIRED KNOWLEDGE & SKILLS:
- Ability to work competently with computer-based charting and other clinical and non-clinical software programs.
- Adaptability to change and good organizational skills required. Ability to read and communicate effectively in English.
- Can be expected to do presentations as directed. Working knowledge of criteria for Medicare, Medicaid, HMO, and private insurance carrier’s coverage details.
- Ability to advocate for patients. Ability to operate office equipment. Possess critical thinking skills.
- Leadership skills required for role include effective mentoring, coaching, counseling, time management, problem solving, and strategic planning.
- Demonstrates initiative and proactive approach to problem resolution.
- Ability to effectively interact with insurance companies and community healthcare recourses.
- Ability to work in a stressful, fast paced environment.
- Must master Microsoft Office Products, i.e. Excel, Word etc.
- Understand CMI, patient status, InterQual Criteria, Milliman Criteria, and Transfer DRGs.
- Has the maturity to work independently and remotely.
- Education: Bachelor’s degree required; Master’s degree preferred.
- Experience (Type & Length): Three to five years of acute medical/surgical experience plus three to five years of Case Management experience.
- Certification/Licensure: RN license required; Certification in Case Management (CCM) strongly preferred.
- Software/Hardware: Strong knowledge in Microsoft Office applications – Word, Excel, Access, PowerPoint.
- Other: Understanding of the health care delivery setting.
About Steward Health Care
Nearly a decade ago, Steward Health Care System emerged as a different kind of health care company designed to usher in a new era of wellness. One that provides our patients better, more proactive care at a sustainable cost, our providers unrivaled coordination of care, and our communities greater prosperity and stability.
As the country's largest physician-led, minority-owned, integrated health care system, our doctors can be certain that we share their interests and those of their patients. Together we are on a mission to revolutionize the way health care is delivered - creating healthier lives, thriving communities and a better world.
Steward is among the nation’s largest and most successful accountable care organizations (ACO), with more than 5,500 providers and 43,000 health care professionals who care for 12.3 million patients a year through a closely integrated network of hospitals, multispecialty medical groups, urgent care centers, skilled nursing facilities and behavioral health centers.
Based in Dallas, Steward currently operates 33 hospitals across Arizona, Arkansas, Florida, Louisiana, Massachusetts, Ohio, Pennsylvania, and Texas.
Steward Health Care is proud to be a minority, physician owned organization. Diversity, equity, inclusion and belonging are at the foundation of the care we provide, the community services we support and all our employment practices. We do not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity, and or expression or any other non-job-related characteristic.