Top Managed Care Executive jobs in Rock Island, IL

Insurance Managed Care RN - UR/CM

Precedence, Inc., Rock Island, IL

Remote or Hybrid with Experience - Based Off Of Location

Full-Time Benefits

M-F, 8-5

The Managed Care RN Utilization/Case Manager, under the direction of the Director of Managed Care serves a key role in coordinating the patient’s/enrollees interdisciplinary providers/services to assess and effectively use resources and to track and minimize the inappropriate use of such resources while providing the right care at the right level at the right time. This role is responsible for utilization management and case management for patients/enrollees. This includes payment authorizations, clinical coordination, integration and facilitation of all care and services for the patient by all members of the health care team.

This role performs admission assessment, continued stay reviews all according to established criteria of third party carriers, and as found necessary on cases with third party payor review. Monitoring of plan of care to address physical and psychosocial needs, and provide problem solving assistance. Coordinates services, discharge planning, referrals to appropriate community agencies and assists with Advance Directives when appropriate. Responsible for reviewing and updating critical paths with healthcare team when applicable. Also, assessing, monitoring, analyzing and documenting resources utilized in the provision of patient care.

Why UnityPoint Health?

• Culture – At UnityPoint Health, you Come for a fulfilling career and experience  a culture  guided by uncompromising values and unwavering belief in doing what's right for the people we serve.
• Benefits – Our competitive  Total Rewards  program offers benefits options like 401K match, paid time off and education assistance that align with your needs and priorities, no matter what life stage you’re in.
• Diversity, Equity and Inclusion Commitment – We’re committed to ensuring you have a voice that is heard regardless of role, race, gender, religion, or sexual orientation.
• Development – We believe equipping you with support and  development opportunities  is an essential part of delivering a remarkable employment experience.
• Community Involvement – Be an essential part of our core purpose—to improve the health of the people and communities we serve.

Visit us at UnityPoint.org/careers to hear more from our team members about why UnityPoint Health is a great place to work.  https://dayinthelife.unitypoint.org 

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• Performs utilization and case management reviews using established criteria to confirm medical necessity, appropriate level of care and efficient use of resources and payment approval.
  • Applies utilization criteria using designated software to complete documentation related to utilization review activities in an accurate and timely manner for the purpose of providing information for other members of the healthcare team and to facilitate decision making.
  • Requests reviews with physician advisors, and/or Executive Health Resources (EHR), as appropriate, if admission or continued stay criteria are not met, assuring appropriate and timely level of care status.
  • Applies accepted potentially avoidable day logic to reviews so that accurate and timely data collection may occur.
  • Conducts payment authorizations and coordinated payment denials while meeting timeliness guidelines.

• Serves as a resource to internal and external staff on issues related to utilization management
• • Maintains current knowledge of Utilization and Case Review Methodology, software, criteria and regulations governing various payment systems.
  • Maintains current knowledge of URAC guidelines
  • Coordinates and monitors appeals internal and with outside organizations used for Second Level Review (e.g. IRO) as needed
  • Works with physicians regarding utilization issues as needed.
  • Ensures appropriate discharge/follow up planning
  • Ensures case coordination with client’s health care providers
  • Provides utilization management and case management to designated enrollees. Assuring that all enrollees receive clinically sound triage/referral and ongoing care management services for medical needs
  • Maintains 100% compliance with the laws, standards, rules and regulations of regulatory agencies including but not limited to: URAC, Medicaid, Medicare
  • Consulting with the medical director/peer reviewer on all high-risk and/or complicated cases, re-admissions and stays over six (6) days
  • Provides documentation of enrollee contacts and clinical care as it occurs.
  • Brings any questions or concerns to supervisor for resolution to help facilitate work being meaningful and fulfilling.
  • Brings a passionate, positive and compassionate attitude to work.
  • Coordinate the development of patient centered case management.

Education:

• Registered Nurse

Experience:

• 5 years of nursing experience

License(s)/Certification(s):

• Registered Nurse – Illinois Licensed

Knowledge/Skills/Abilities:

• Professional Communication – written & verbal
• Customer/patient focused
• Self-motivated
• Managing priorities/deadlines
• Flexibility to adapt to changing priorities or needs
• Planning and organizing skills
• MS Office proficiency (Outlook, Word)
• Ability to give work direction to non-clinical staff

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