Pre-employment modules may be required for this role. Please upload any certifications or health documents you have to your profile to expedite your on-boarding process.

Additional Details:

Required Skills/Experience: 8 years’ clinical care or nursing experience, 3 years of which should be in chart review, risk management, or related quality service. Knowledge of conducting and reviewing medical records for medical necessity, level of care, and public and private insurance reimbursement. Basic ICD-9 and CPT coding. Regulations as set forth by The Centers for Medicare Medicaid Services. Proficient in medical terminology, anatomy, physiology, and concepts of disease.

Preferred Credentials: Case Management certification by a recognized certifying organization (i.e., NCQA, CCMC) preferred.

Special Requests: Travelers must live at least 50 miles from the facility address.

Unit Details: Manages patient progression of care, promotes evidence-based protocols, ensures the appropriateness of interventions, and expedites care delivery for patients admitted. Directs patient care services to ensure a timely and appropriate patient discharge. Reviews patients’ records and evaluates patient progress. Performs continuing review of the patient hospitalization to specifically monitor the necessity for and appropriateness of hospitalization, length of stay, and quality of care. Provides UM and review functions to the Purchased/Referred Care Services program for SEARHC beneficiary patients admitted to other facilities. Obtains and reviews necessary medical reports and treatment plans as requested by regulatory agencies or payers. Reviews and validates physician orders, reports progress and unusual occurrences on patients. Reviews new hospital admissions to assess patient conditions and needs in order to develop personalized treatment plans. Provides appropriate or required information to patients and/or their families regarding their healthcare benefits. Ensures documentation supports the UM functions and communicates with payers within required timeframes. Reviews information, communicates results to claims adjusters, and enters billing information as appropriate. Prepares information for notification letters for providers, staff, and patients. Receives and processes requests for appeal of denials. Responds to complaints per UM review guidelines. Maintains utilization review and appeal logs. Supports clinical improvement activities by providing quality review. Performs tumor registry functions.