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Company Contact Info
19 South LaSalle Street
Chicago, IL 60602
- Juliana Fruzzetti
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AltaStaff • Chicago, IL
Posted 30 days ago
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AltaStaff works with different Managed Care Organizations in the state of Illinois. Please apply if you are interested in discussing the following position as an Registered Nurse Case Manager. This is a temporary, 5 month opportunity with benefits and a competitive salary offered.
Under the direction of the Manager, Utilization Management/Transition of Care, the Utilization Management Specialist is responsible for performing all utilization management activities to include reviewing, screening, processing and authorizing referral requests from all providers.
ESSENTIAL FUNCTIONS: The major responsibilities of this Review Nurse include:
Performs prospective, initial, concurrent and retrospective reviews for all requested services to include but not limited to the following: inpatient admissions, facility requests, durable medical equipment (DME) and outpatient and home health services
- Monitors level and quality of care of services being provided and approved
- Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs
- In conjunction with, and under the supervision of VP, Medical Management, Medical Director and Director, UM, evaluates and provides feedback as needed to treating physicians regarding a member's discharge and home care plans and available covered services including identifying alternative levels of care that may be covered
- Monitors utilization reports to assure compliance with reporting and turnaround. Addresses care issues with VP, Medical Management, Medical Director, Director, UM and Manager, UM when appropriate
- Coordinates an interdisciplinary approach to support continuity of care.
- Provides utilization management, transfer coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed for members
- Coordinates identification and reporting of potential high dollar/utilization cases to reinsurer and finance department for appropriate reserve allocation
- Responsible for the early identification and assessment of members for potential inclusion in a comprehensive care coordination program. Refers members for care coordination accordingly
- Actively participates in the discussion and notification processes that result from the clinical utilization reviews with facilities and service providers
- Prepares CMS-compliant notification letters of NON-certified and negotiated days and services within established time frames. Reviews all NON-certification files for correct documentation
- Assists in the identification and reporting of Potential Quality of Care concerns. Responsible for assuring these issues are reported to the Quality Improvement Department
- Performs other related activities as assigned
- M-F 8 AM-5PM
- Environmental Conditions: The majority of duties are performed in a controlled office environment; desk work may involve extended periods of sitting, phone time, typing on PC keyboard.
- Associates Degree, BSN preferred.
- Nursing: 3 years
- Utilization Review: 2 years
Required license or certification:
- Registered Nurse (RN)