Concurrent Review Case Manager
Lumeris
full-time
Posted on:
Location Type: Remote
Location: United States
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Salary
💰 $72,800 - $97,400 per year
About the role
- Performs pre-service and concurrent reviews of requested services within specified department timelines.
- In-Patient reviews include Acute Facilities and Skilled Nursing Facilities.
- Out-Patient reviews include service authorizations and home health care.
- Applies clinical knowledge for the interpretation and evaluation of clinical data to ensure compliance with established criteria.
- Reviews authorization requests for services according to adopted Plan and InterQual criteria.
- Reviews questionable cases with facility team members and the Medical Director to assess if care requested meets medical necessity criteria.
- Documents denial process and provides timely provider and member notification following specified timelines and department protocols.
- Initiates early discharge planning, incorporating transition of care plans, with facility team members and plan's primary care providers.
- Initiates and coordinates facility transfers, incorporating transition of care plans.
- Coordinates with appropriate state representatives and internal team(s) on member and provider appeals.
- Makes appropriate referrals to quality improvement, behavioral health, and complex case management.
- Completes retrospective chart reviews and pended claims reviews as requested.
- Maintains strong collaborative working relationships with specialty, ancillary, and primary care providers.
- Documents completely and accurately within an electronic clinical record.
- Provides education on the utilization management process to members and providers as requested.
- Ensures utilization management program compliance and successful reimbursements by understanding applicable contract terms.
- Participates in care management as a member of an interdisciplinary team.
- Maintains knowledge of pertinent regulatory and accrediting requirements.
- Maintains HIPAA standards and compliance with all state and federal regulations.
- Ensures confidentiality of protected health information.
- Performs special projects as assigned.
Requirements
- Licensed Registered Nurse (RN) in the state of residence is required, with the ability to obtain additional state licensure as needed
- 3+ years clinical nursing experience or the knowledge, skills, and abilities to succeed in the role
- Strong verbal and written communication skills
- Strong Ability to use good judgment
- Strong Effective organizational and customer service skills
- Working knowledge of contract terms as it relates to utilization management program compliance and reimbursement
- Working knowledge of HIPAA regulations and NCQA standards
- Ability to work effectively within a team
- Firm computer skills including Microsoft Office
- Ability to multi-task and prioritize work
- Preferred 2+ years of utilization review, discharge planning, or managed care
- Working knowledge of Medicare guidelines
- Knowledge and use of InterQual Criteria
Benefits
- Medical, Vision and Dental Plans
- Tax-Advantage Savings Accounts (FSA & HSA)
- Life Insurance and Disability Insurance
- Paid Time Off (PTO, Sick Time, Paid Leave, Volunteer & Wellness Days)
- Employee Assistance Program
- 401k with company match
- Employee Resource Groups
- Employee Discount Program
- Learning and Development Opportunities
- And much more...
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical nursingutilization reviewdischarge planningmanaged careInterQual criteriaMedicare guidelineschart reviewsclaims reviewscompliance evaluationtransition of care planning
Soft Skills
verbal communicationwritten communicationjudgmentorganizational skillscustomer serviceteamworkmulti-taskingprioritization
Certifications
Licensed Registered Nurse (RN)