Senior Manager, Customer Centricity – Business Cards & Payments
Capital One
Case Manager – Utilization Management
Lehigh Valley Health Network
full-time
Posted on:
Location Type: Remote
Location: Remote • Pennsylvania • 🇺🇸 United States
Visit company websiteJob Level
JuniorMid-Level
About the role
- Ensures appropriate use of hospital resources by reviewing all patients admitted to the hospital and evaluating appropriateness of admission using approved criteria.
- Ensures appropriate patient class assignment (inpatient, outpatient) to ensure compliance with third party payer requirements.
- Acts as a resource and educates on the appropriate level of care assignment, patient class, and utilization management-related work.
- Provides timely, accurate, and thorough clinical reviews to assist in the patient class decision-making process.
- Develops and implements methods, policies, and procedures to improve departmental efficiency and overall effectiveness.
- Partners with unit-based care managers to ensure appropriate exchange of information regarding patient financial status, diagnosis, and discharge needs.
- Works closely with precert/preservices, appeals, patient access, billing, coding, and finance to complete all reviews thoroughly and accurately.
- Completes clinical review and assesses the appropriateness of admission through the evaluation of evidence-based criteria.
- Works collaboratively with management, peers, and other colleagues outside of the department to facilitate appropriate patient class assignment, assist in problem-solving with complex cases, and help investigate cases to maximize reimbursement.
- Performs patient class change process in a timely and efficient manner at the direction of the physician advisor, attending provider, and/or in conjunction with the appropriate payer.
- Documents authorizations and downgrades according to departmental policy and procedure.
- Participates in the Performance Improvement process including assessment, implementation, and evaluation of new/updated processes to ensure goals are met each FY, as well as all procedures are streamlined for effectiveness and efficiency.
Requirements
- Specialized Diploma in nursing
- 2 years of previous utilization review experience.
- Knowledge of utilization management as it relates to third party payers.
- Ability to maintain the strictest adherence to HIPAA while maintaining confidentiality of all PHI.
- Ability to work in a team environment demonstrating flexibility to work toward common goals based around prioritized needs.
- Ability to be attentive to detail and maintain a positive attitude.
- Ability to complete work assignments accurately and in a timely manner while managing multiple responsibilities and prioritizing all tasks effectively.
- Demonstrates proficiency with all work queue processes.
- Knowledge of evidence-based clinical decision support criteria.
- RN - Licensed Registered Nurse_PA - State of Pennsylvania Upon Hire
Benefits
- Health insurance
- 401(k) matching
- Flexible working hours
- Paid time off
- Remote work options
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
utilization reviewutilization managementclinical reviewevidence-based criteriapatient class assignmentadmission evaluationperformance improvementdocumentationbillingcoding
Soft skills
attention to detailteamworkflexibilityproblem-solvingcommunicationpositive attitudetime managementprioritizationcollaborationeducational skills
Certifications
Licensed Registered NurseSpecialized Diploma in nursing
