RN Case Manager Utilization Review

Up to $15,000 Sign-On bonus for experienced Registered Nurse / RN

Saint Vincent Hospital offers a whole new experience in health care. By combining our advanced, state-of-the-art facility with our commitment to providing the best quality of life to the many members of our Worcester community. Saint Vincent Hospital excels at offering the best care in a friendly atmosphere. From our advanced heart and vascular services, to our comprehensive orthopedics and rehabilitation programs, our robust surgical facility including our Da Vinci robotic surgery and Cyberknife technology, to our comfortable and compassionate women & infants programs - you don't have to travel far for high-quality health care: We're right here, in the heart of Worcester.

Position Summary:
The individual in this position is responsible to facilitate effective resource coordination to help patients achieve optimal health, access to care, and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity. This position manages medical necessity process for accurate and timely payment for services which may require negotiation with a payer on a case-by-case basis. This position integrates national standards for case management scope of services including: Utilization Management services supporting medical necessity and denial prevention; Coordination with payers to authorize appropriate level of care and length of stay for medically necessary services required for the patient; Compliance with state and federal regulatory requirements, TJC accreditation standards, and Tenet policy; and Education provided to payers, physicians, hospital/office staff, and ancillary departments related to covered services and administration of benefits.
Responsible for providing accurate medical necessity screening and submission for Physician Advisor review. Securing and documenting authorization for services from payers. Managing concurrent disputes. Collaborating with payers, physicians, office staff, and ancillary departments. Timely, complete, and concise documentation in the Tenet Case Management documentation system. Maintenance of accurate patient demographic and insurance information. Identification and documentation of potentially avoidable days. Identification and reporting over and underutilization.

Onboarding Process: Please be advised that candidates must successfully complete a background check and pre-employment health screening which includes a drug screen.

Qualifications:
Required: Graduate of an accredited school of nursing
Preferred: Academic degree in nursing (bachelor's or master's)
Required: 2 years of acute hospital or behavioral health patient care experience with at least 1 year utilization review in an acute hospital or commercial/managed care payer setting

Certifications:
Required: RN. Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy. Active RN license for state(s) covered.
Preferred: Accredited Case Manager (ACM)

Tenet complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.