This position is in-person, and not eligible for remote work.
Position Summary
The RN Utilization Review Manager is responsible for the coordination of the patient's care and services and manages the
resource utilization for all skilled patients based upon the patient’s clinical needs and care plan. Promotes quality care using a
collaborative process that coordinates, monitors, and evaluates services according to the needs of and interpersonal contact
with patients in accordance with all applicable laws, regulations, and Life Care standards. Works together with the patient
and family, care team, payers, and external entities to assure patient safety and attain or maintain the highest practicable
physical, mental, and psychosocial well-being of each patient and promote a safe transition from the facility to the next
provider or care setting
? Reports to Executive Director (ED) or Director of Nursing (DON)
Working Conditions
May have weekend supervision responsibilities
Attends and participates in continuing education programs
Works in department as well as throughout facility
Subject to frequent interruptions
? Involved with patients, associates, visitors, government agencies/personnel, etc. under all conditions and circumstances
Subject to hostile and emotionally upset patients, family members, etc.
Works beyond normal working hours, on weekends and holidays, and in other positions temporarily as necessary
Subject to falls, burns from equipment, odors, etc. throughout the workday
Possible exposure to infectious waste, diseases, conditions, etc., including exposure to the AIDS and hepatitis B viruses
Education, Experience, and Licensure/Certifications
Must possess a nursing diploma (associate's or bachelor's degree in nursing)
Must be currently licensed/registered in applicable State. Must maintain an active Registered Nurse (RN) license in good
standing throughout employment.
One (1) year of clinical experience in post-acute care setting preferred
? Prior case management, utilization review, and discharge planning experience preferred
Certified Case Manager (CCM) or Board Certification in Nursing Case Management (RN-BC) preferred
Specific Requirements
Must be able to generate written communication that is clear, concise, and well-organized
Must have excellent organizational skills and be efficient in prioritizing and managing time and assignments
Must contribute to the organization's goals and objectives and support the organizational strategic plans
Must have knowledge of medical necessity review guidelines for commercial, Medicare, Medicare Advantage, and Medicaid
insurance products
Must have expert knowledge in field of practice
Must possess the ability to make independent decisions when circumstances warrant such action
Must be knowledgeable of nursing practices and procedures as well as the laws, regulations, and guidelines governing
nursing functions in the post-acute care facility
Must have the ability to implement and interpret the programs, goals, objectives, policies, and procedures of the nursing
department
Must perform proficiently in all applicable competency areas
Maintains professional working relationships with all associates, vendors, etc.
Maintains confidentiality of all proprietary and/or confidential information
Must understand and follow company policies including harassment and compliance procedures
Displays integrity and professionalism by adhering to Life Care’s Code of Conduct and completes mandatory Code of
Conduct and other appropriate compliance training
Essential Functions
Must be able to demonstrate efficient use of relevant computer systems including but not limited to the ability to enter and
retrieve data
Must be able to use knowledge of insurance criteria and regulations in order to expedite appropriate use of resources and
compliance with third party payer contracts
Must be able to manage the resource utilization (routine and ancillary) for all skilled patients based upon the patient’s clinical
needs and care plan
Must be able to work closely with business office manager to obtain, oversee, and communicate certifications, authorizations,
any denial of payments, and notice of non-coverage
Must be able to serve as liaison to external case managers, family, physicians, and community resources
Must be able to have the ability to train and education patients, families, associates, and other providers of care
Must be able to implement the standards of practice for care management, ethical performance, and functions relevant to
coordination of care
Must exhibit excellent customer service and a positive attitude towards patients
Must be able to assist in the evacuation of patients
Must demonstrate dependable, regular attendance
Must be able to concentrate and use reasoning skills and good judgment
Must be able to communicate and function productively within an interdisciplinary team
Must be able to sit, stand, bend, lift, push, pull, stoop, walk, reach, and move intermittently during working hours
Must be able to read, write, speak, and understand the English language
? Must be able to lift 35 lbs floor to waist, lift 35 lbs waist to shoulder, lift and carry 35 lbs, and push/pull 35 lbs