K.A. Recruiting


Utilization Review Nurse / RN Case Manager

Manchester, NH 03103

Job Type: Nursing Opportunities - Staff Level Job Number: KMC221188

Position Title:

Utilization Review Nurse/RN Case Manager

We are seeking a full time Utilization Review RN/ Case Manager to cover the Manchester & Portsmouth areas of New Hampshire!

SCOPE:

Responsible for determining medical necessity, appropriateness of care, level of care, and quality of care medical reviews for patients that has been contracted to serve in accordance with all state mandated regulations and insurance company contracts program.

 

QUALIFICATIONS:

  • Current RN license issued by the State of New Hampshire Board of Nursing
  • Strong knowledge of clinical UR and QA, Medicaid, Medicare guidelines and covered services
  • Strong knowledge of InterQual/Milliman,MCG, ICD 10 Codes, and MCG Criteria
  • Strong in Microsoft Office
  • Working knowledge of behavioral health, substance abuse and human service resources.
  • Case Management certification desired

 

SCHEDULE:

Monday –Friday 8:00-4:00

On-Call rotation for after hours coverage

Flexibility as program needs dictate

 

PRIMARY EXPECTATIONS:

  • Coordinates and conducts initial, concurrent, and retrospective medical record reviews as needed.
  • Makes utilization decisions in accordance with evidenced based criteria for New Hampshire.
  • Performs case management duties as part of an Integrated Case Management team serving New Hampshire clients with chronic illnesses and/or disabilities in accordance with agency policy, applicable state regulations and accepted professional standards of practice.
  • Execute the strategic vision and initiatives of CMCC, build relationships with our partners and facilities across the care continuum.
  • In-facility program development for discharge planning consultation which includes oversight of CMCC multidisciplinary team and subcontractors for benefits, equipment, and home modifications to drive effective discharges
  • Function as lead of CMCC discharge planning program charter which includes regularly scheduled meetings with identified stakeholders
  • Work is performed with minimal supervision and a high degree of self initiative and independence in keeping with the standards of excellence set forth by the program.
  • Perform all duties in an ethical and professional manner, support the team concept and pursue professional growth and development.
  • Maintain harmonious relations and demonstrate tact and sensitivity in responding to staff, students, parents/guardians and others.
  • Accept and render constructive criticism in a professional and mature manner.

PRIMARY COMPETENCIES:

Uphold Standards of Practice for Case Management, as follows:

  • Address the total individual, inclusive of medical, psychosocial, behavioral, and spiritual needs.
  • Collaborate efforts that focus upon moving the individual to self-care whenever possible.
  • Increase involvement of the individual and care giver in the decision-making process

 

  • Minimize fragmentation of care within the healthcare delivery system.
  • Use evidence-based guidelines, as available, in the daily practice of case management.
  • Focus on transitions of care, which includes a complete transfer to the next care setting provider that is effective, safe, timely, and complete.
  • Improve outcomes by utilizing adherence guidelines, standardized tools, and proven processes to measure a clients understanding and acceptance of the proposed plans, their willingness to change, and their support to maintain health behavior change, inclusive of medication adherence.
  • Strive to promote client self-advocacy and self-determination
  • Conduct comprehensive assessments of clients health and psychosocial needs, including health literacy status and deficits, and develop an integrated case management plan collaboratively with the client and family or caregiver.
  • Conduct nursing assessments as appropriate per payer source and contract to determine eligibility for programs/services and perform annual redetermination assessments as needed.
  • Plan, direct coordinate and evaluate all nursing and personal care activities required for Private Pay clients.
  • As part of the Integrated Case Management Model be an educator and resource to the client, the family or caregiver, and members of the health care delivery team about treatment options, community resources, insurance benefits, psychosocial concerns, case management, etc., so that timely and informed decisions can be made.
  • Participate in program Shared Governance Committees and community meetings and organizations as appropriate to the position or assigned by the supervisor.
  • Encourage the appropriate use of health care services and strive to improve quality of care and maintain cost effectiveness on a case-by-case basis.
  • Improve client safety and satisfaction.

 

JOB# KC3534

Please click APPLY ONLINE or email us a copy of your resume directly (my email is next to my profile). Be sure to check out all of our jobs at http://jobs.ka-recruiting.com. We look forward to working with you!

Kristin Campbell
Healthcare Recruiter

Hello! Thanks for checking out my job openings. I specialize in recruiting and placing healthcare professionals into full time permanent positions nationwide. I work with top hospitals/clients on Physician, Advanced Level Practitioners, Therapy, Nurses, Nurse Leadership, Laboratory, and other Allied Health Recruitment. I look forward to placing you into a long term satisfying career!

Send an email reminder to:

Share This Job:

Related Jobs:

Login to save this search and get notified of similar positions.

Your Partner in Healthcare Recruiting