As a Utilization Management Nurse/Social Worker, you'll play a crucial role in our multidisciplinary team, ensuring that patients progress seamlessly through their care journey according to appropriate admission statuses. Proficient in Utilization Review processes, you'll maintain effective procedures to meet regulatory and reimbursement requirements for various payers, both commercial and government. 100% Remote - However, Only candidates on EST - Eastern USA time zone are considered.
Current Nurse license or Clinical License. Associate's degree; Bachelor's degree preferred. 3-5 years of acute hospital experience and 3 years of Utilization Management experience. Hospital case management experience is advantageous. Proficiency in federal and state regulations (DOH, Medicaid/Medicare) and familiarity with third-party payers and managed care principles.
Conduct concurrent and continued stay Utilization Management reviews, ensuring accurate data tracking, evaluation, and reporting. Lead or participate actively in process improvement initiatives, collaborating with various departments and multi-disciplinary teams. Efficiently manage a diverse workload in a fast-paced, ever-evolving regulatory environment. Foster positive collaboration with the Care team to facilitate timely patient progression during their stay.
Best Value
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