Nursing diploma (associate's or bachelor's degree) required
Active Registered Nurse (RN) license in good standing
1 year of clinical experience in post-acute care preferred
Experience in case management, utilization review, and discharge planning preferred
Certified Case Manager (CCM) or RN-BC preferred
Knowledge of medical necessity review guidelines for various insurance products
Strong organizational skills and ability to prioritize tasks
Responsibilities
Coordinate patient care and resource utilization based on clinical needs
Promote quality care through collaboration with patients, families, and care teams
Manage certifications, authorizations, and payment denials with business office manager
Serve as liaison to external case managers and community resources
Train and educate patients, families, and care providers
Implement standards of practice for care management and ethical performance
Exhibit excellent customer service and maintain a positive attitude towards patients
Benefits
Participation in continuing education programs
Opportunity for professional development
Supportive work environment with a focus on patient safety
Engagement with interdisciplinary teams
Potential for leadership responsibilities on weekends
Full Job Description
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
About Life Care Centers of America
Life Care Centers of America is a privately held company that operates nursing homes, assisted living facilities, and retirement communities in the United States. The company was founded in 1970 and is headquartered in Cleveland, Tennessee. Life Care Centers of America provides a range of services, including skilled nursing care, rehabilitation, Alzheimer's and dementia care, and hospice care. The company operates more than 200 facilities in 28 states.
