ESSENTIAL DUTIES AND RESPONSIBILITIES:

The Utilization Review RN Case Manager shall be responsible for all aspects of the utilization review process as directed by the Supervisor of Utilization Review. Activities shall include, but not be limited to, inpatient and outpatient review, admission review, discharge planning, retrospective review, readmission review, large case management screening/identification, identification and communication of large claim potential, development, review, revision, and implementation of quality improvement programs and protocols (as directed by the Supervisor of Utilization Review), excellent coordination and communication of medical information with large case and disease management and payers (as appropriate), appropriate usage of physician advisors, adherence to URAC requirements and LHCM. documentation, quality, and productivity standards, completion of requests for attending physician statements, and customer service support.

The Utilization Review RN Case Manager is responsible, on a daily basis, for completing the “tickler”, returning telephone and voice mail messages within established timeframes, accurately and adequately documenting all interactions, checking and responding to e-mail, faxes, and regular mail, interacting with all internal and external customers in a positive, proactive, and helpful manner, and providing any and all necessary support to the Supervisor of Utilization Review and the entire LHCM team. The UR Case Manager shall complete the LHCM Orientation and Training Course that includes policies and procedures and URAC UM Standards, be familiar and supervise the activities of the non-clinical administrative staff relative to the UR function, utilize telephones, access the server, or other software that may be provided by LHCM to perform daily duties, and be familiar with the Clinical Review Guidelines.

The UR Case Manager shall be responsible for providing all aspects of excellent customer service and development, maintaining confidentiality, completing an orientation and participating in an ongoing training program which includes policies and procedures, URAC UM Standards, and clinical review guidelines.

The UR case manager only certifies care or services. If the care or service requested is not meeting initial clinical review criteria, then the case is referred to a peer clinical reviewer.

QUALIFICATIONS:

  • Registered Nurse with a minimum of 5 years of recent clinical nursing experience
  • Bachelor’s Degree and/or Certification in UR, Case Management, or a related field-preferred
  • Excellent Written and Oral Communication
  • Positive, proactive team-oriented approach/attitude
  • Excellent Computer skills
  • Holds an active, unrestricted RN license that allows him/her to practice in a state or territory of the United States.

Equal Employment Opportunity Policy Statement: Lucent Health Solutions, Inc. is an Equal Opportunity Employer that does not discriminate based on actual or perceived race, creed, color, religion, alienage or national origin, ancestry, citizenship status, age, disability or handicap, sex, marital status, veteran status, sexual orientation, genetic information, gender identity, gender expression, transgender status, arrest record, or any other characteristic protected by applicable federal, state or local laws. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.

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