Work Type: PER DIEM
Work Schedule: VARIABLE
Location: CAPE FEAR VALLEY MEDICAL CENTER
Position Summary:
The Utilization Management Case Manager is responsible for performing the initial and concurrent Utilization Review determination on all patients admitted or placed on observation status. Manages the provision of cost containment services by determining the medical necessity and appropriateness of outpatient and inpatient admissions. Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in health care facility to comply with governmental and insurance company reimbursement policies. Maintains compliancy with regulation changes affecting utilization management and performs utilization review in accordance with all state mandated regulations. Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct review. Performs continued stay reviews and ensures appropriate and cost-effective healthcare services to patients. Works collaboratively with Utilization Management Manager and payers to ensure that denials and appeals are tracked and responded to in a timely and appropriate manner.
Knowledge, Skills, and Abilities:Minimum three to five years’ experience in Acute Care setting. Medical/Surgical and/or ICU experience preferred. Case Management experience required. Additional minimum of one year in managed care claims/reimbursement or other healthcare field preferred. Strong clinical background. Knowledge of professional nursing principles, clinical processes and clinical interventions. Excellent interpersonal communication and negotiation skills. Able to communicate effectively and work with people of all social, economic, and cultural background. Self-motivated, proven written, telephonic and electronic communication skills, assertive and persuasive in interactions with customers, peers, management and core staff served. Understanding of criteria and measurement outcomes. Knowledge of third party payor requirements including managed care, reimbursement and utilization management. Proficiency with various computer programs, to include Microsoft Office, Midas, Allscripts, ValleyLink, eHIM, EMSTAT, Teletracking, SMS, Megacare, and TraceVue. Skills necessary to build credible and effective relationships with physician leadership, the internal and external customer. Flexible, open-minded and adaptable to change. Models positive change. Ability to demonstrate respect and team building. Able to prioritize and process multiple tasks, responsibilities and work projects, demonstrating strong organizational and time management skills. Demonstrated ability to analyze related information, plan effective actions and follow through reliably to meet expectations. Ability to work and promote interdependence demonstrated in actions resulting in sound judgment with interactions with physicians, peers, patients and /or designee, payors, support service personnel. Ability to work collaboratively with department staff, physicians and healthcare professionals at all levels to achieve established goals, improve quality of outcomes, maintain or exceed Joint Commission standards and state mandates as they apply to the department operations.
Required Education, Licenses, and Certifications:
- Associate's Degree Nursing
Preferred Education, Licenses, and Certifications:
- Bachelor's Degree Nursing
Or ACM
Other Information:Some light carrying and lifting may be required. Occasional walking may be required to access all areas of the Medical Center. Ability to effectively communicate orally to patients, family members, personnel and physicians. Near visual acuity to proofread hand or typewritten materials. Manual ability to use telephones and computer keyboard. Position involves sitting for extended periods of time performing data entry into a computer.
*About Cape Fear Valley Health System*
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For exceptional healthcare come to Cape Fear Valley Health System - where caring employees are committed to integrity, patient-centeredness and excellence throughout the entire healthcare process. At Cape Fear Valley Health System, our goal is to improve the quality of every life we touch. To achieve that, our Fayetteville doctors, surgeons and staff are committed to excellence in every aspect of the healthcare process. Our values of patient-centeredness, integrity, innovation, teamwork, diversity and accountability help us create a better experience for every patient, every time. At Cape Fear Valley, our employees and physicians proudly serve a seven-county region of southeastern North Carolina, including Fayetteville, Fort Bragg, Hope Mills, Raeford, Lumberton, Elizabethtown, Clinton, Lillington, Dunn, and beyond. Our medical facilities include Cape Fear Valley Medical Center, Highsmith-Rainey Specialty Hospital, Cape Fear Valley Rehabilitation Center, Behavioral Health Care, Bladen County Hospital, Hoke Hospital, Central Harnett Hospital, Betsy Johnson Hospital, as well as several medical offices and specialty clinics spread throughout the Cape Fear region. Our newest clinic is the Stephen A. Cohen Military Family Clinic at Cape Fear Valley. It offers comprehensive mental healthcare, at no or low-cost, to area veterans and their families coping with the invisible wounds of war.
*Screening Requirements: Drug Screen, Background Check, License and Employment reference verification.*
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Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity
Job Type: Part-time
Schedule:
- Monday to Friday
- Rotating shift
- Weekend availability
Work Location: In person