Utilization Review Manager (Registered Nurse/RN) LPN Case manager

This position is in-person, and not eligible for remote work. Must be able to commute to facility: 1 Great Rd. Acton MA 01720

      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