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: At least one (1) year of experience must be on a medical/surgical ward or unit. Two (2) years of experience as a Case Manager in an alternate medical setting such as a clinic or physician’s office performing utilization review or discharge planning.

Required Credentials: Highest level of education as stated on the resume.

Unit Details: Utilization review and discharge planning activities. Obtains and evaluates medical records for in-patient admissions to determine if required documentation is present. Obtains appropriate records as required by payor agencies and initiates Physician Advisories as necessary for unwarranted admissions. Conducts on-going reviews and discusses care changes with attending physicians and others. Formulates and documents discharge plans. Provides on-going consultation and coordination with multiple services within the hospital to ensure efficient use of hospital resources. Identifies pay source problems and provides intervention for appropriate referrals. Coordinates with the admitting office to avoid inappropriate admissions. Coordinates with clinic areas in scheduling specialized tests with other health care providers, assesses pay source, and authorizes payment under the Medically Indigent Adult program as necessary. Reviews and approves surgery schedules to ensure elective procedures are authorized. Coordinates with correctional facilities to determine appropriate use of elective procedures, durable medical goods, and other services. Answers questions from providers regarding reimbursement, prior authorization, and other documentation requirements. Teaches providers the documentation requirements of payor sources to maximize reimbursement to the hospital. May assist in training Utilization Review Nurse I workers.