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.

Preferred Credentials: Case Management certification by a recognized certifying organization, such as NCQA, preferred.

Unit Details: Manages patient progression of care, promotes evidence-based protocols, ensures the appropriateness of interventions, expedites care delivery for patients admitted, and directs patient care services to ensure a timely and appropriate patient discharge. Performs continuing review of the patient hospitalization to monitor the necessity for and appropriateness of hospitalization, length of stay, and quality of care. Provides utilization management and review functions for Purchased/Referred Care Services patients admitted to other facilities. Reviews and validates physician orders, medical reports, and treatment plans; communicates with regulatory agencies, payers, providers, staff, patients, and families regarding care plans and healthcare benefits. Supports denials and appeals review, maintains utilization review and appeal logs, and performs tumor registry functions. Uses medical record review and basic ICD-9 and CPT coding in daily work.

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.

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