Utilization Review Case Manager (45966)

Requirements

• Maintains regular attendance and punctuality.
• Conduct thorough prospective, concurrent, and retrospective medical reviews for managed care members.
• Collaborate with clinical providers to assess admission status and reviews for continued stay.
• Communicate effectively and compassionately with patients, families, and providers, ensuring timely updates and collaboration.
• Present findings to the medical management committee and convey outcomes clearly and concisely.
• Assess patients’ physical, functional, social, psychological, and financial needs to create a holistic understanding of their care requirements.
• Develop and implement individualized care plans, prioritizing goals based on patient and caregiver preferences.
• Continuously monitor care plans for effectiveness and appropriateness of services provided.
• Assists in coordinating and tracking referrals in conjunction with WIHCC, Inc providers and outside specialists, and collaborates closely with the Inpatient and Outpatient RN Case Managers.
• Provide education and support related to patient care goals and resources.
• Function as a patient advocate, addressing barriers to care and facilitating access to community and cultural resources.
• Stay informed about medical policies and coverage guidelines relevant to position to ensure compliance and quality care.
• Monitor quality and compliance measures using chart audits.
• Maintain accurate and confidential patient records in accordance with documentation standards and regulations.
• Assist with workflow stabilization during high-volume periods.
• Maintains strict confidential policies complying with HIPAA and WIHCC policies due to the sensitive nature of patient information.
• Upholds all principles of confidentiality and patient care to the fullest extent.
• Adheres to all professional and ethical behavior standards of the healthcare industry.
• Adheres to WIHCCs Personnel Policies and Procedures, departmental policies, rules, and regulations.
• Interacts in an honest, trustworthy and dependable manner with patients, employees, visitors, and vendors.
• Possesses cultural awareness and sensitivity.
• Maintains compliance with all Human Resources requirements.
• Performs other duties as assigned.

Benefits

• Health insurance
• Retirement plan
• Paid time off
• Life insurance
• Disability insurance