Case Manager - Utilization Management

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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.

Job Duties

• 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.

• Specialized Diploma in nursing
• 2 years of previous utilization review experience. and
• 2 years 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

• Bachelor's Degree In nursing
• Knowledge of evidence-based criteria such as InterQual criteria and/or MCG criteria.
• ACM - Accredited Case Manager ACMA - State of Pennsylvania Upon Hire and
• CCM - Certified Case Manager CCMC - State of Pennsylvania Upon Hire and
• CMCN - Certified Managed Care Nurse ABMCN - State of Pennsylvania Upon Hire

Lift and carry 7 lbs., continuous sitting >67%, frequent keyboard use/repetitive motion, frequent fine motor activity/wrist position deviation.

Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Lehigh Valley Health Network is an equal opportunity employer. In accordance with, and where applicable, in addition to federal, state and local employment regulations, Lehigh Valley Health Network will provide employment opportunities to all persons without regard to race, color, religion, sex, age, national origin, sexual orientation, gender identity, disability or other such protected classes as may be defined by law. All personnel actions and programs will adhere to this policy. Personnel actions and programs include, but are not limited to recruitment, selection, hiring, transfers, promotions, terminations, compensation, benefits, educational programs and/or social activities.

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