Utilization Care Manager - St. Anne's Hospital
Core
Conducts surveillance over medical necessity of patient care records, ensures appropriate utilization of resources, and manages admission/concurrent authorizations with third-party payers.
Role type
Utilization Care Manager (Clinical)
Builds
Patient care pathways and insurance authorization workflows
Domain
Healthcare / Utilization Review
Required skills
Registered Nurse licensure, InterQual criteria application, Medicare regulatory compliance, clinical documentation, patient appeals management, stakeholder communication
Preferred skills
Master's in Nursing, CPHM certification, case management experience, discharge planning expertise
Technologies
Microsoft Office, Outlook, automated medical record systems
Responsibilities
Apply InterQual level of care screening criteria within one business day of admission; review Medicare patient admissions daily for regulatory compliance; deliver Hospital Issued Notice of Non-coverage (HINN) to beneficiaries; initiate and complete expedited patient appeals; act as liaison with third-party payers and physicians; identify and reduce service delays to improve patient throughput.
Seniority
Mid-level, hands-on IC