Utilization Review Case Mgmt Nurse I
The Utilization Review Case Manager gathers demographic and clinical information on prospective, concurrent and retrospective in-patient admissions and out-patient treatment, certifies the medical necessity and assigns an appropriate length of stay; supporting the goals of the Case Management department, and of CorVel.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:
- Identifies the necessity of the review process and communicates any specific issues of concern to the appropriate claims staff/customer.
- Collects data and analyzes information to make decisions regarding certification or denial of treatment. Documenting all work in the appropriate manner.
- Requires regular and consistent attendance.
- Complies with all safety rules and regulations during work hours in conjunction with the Injury and Illness Prevention Program (IIPP).
- Additional duties as required.
KNOWLEDGE & SKILLS:
- Must have a thorough knowledge of both CPT and ICD coding.
- Effective multi-tasking skills in a high-volume, fast-paced, team-oriented environment.
- Ability to interface with claims staff, attorneys, physicians and their representatives, and advisors/clients and coworkers.
- Ability to promote and market utilization review products with attorneys and claims staff.
- Strong ability to negotiate provider fees effectively.
- Excellent written and verbal communication skills.
- Ability to meet designated deadlines
- Computer proficiency and technical aptitude with the ability to utilize MS Office including Excel spreadsheets
- Strong interpersonal, time management and organizational skills.
- Ability to work both independently and within a team environment.
- Graduate of accredited school of nursing with a diploma/Associates degree (Bachelor of Science degree or Bachelor of Science in Nursing preferred)
- Current Nursing licensure in the state of operation required.
- RN is required unless local state regulations permit LVN/LPN.
- 4 or more years of recent clinical experience.
- Previous experience in the following areas, preferred:
- Prospective, concurrent and retrospective utilization review
- Experience in the clinical areas of O.R., I.C.U., C.C.U., E.R., orthopedics
- Knowledge of the workers’ compensation claims process
- Outpatient utilization review
In order to provide equal employment and advancement opportunities to all individuals, employment decisions at CorVel will be based on merit, qualifications and abilities. Except where required or permitted by law, employment practices will not be influenced or affected by an applicant's or employee's race, color, religion, sex, national origin, ancestry, citizenship, age, handicap or disability, marital status, medical condition or any other characteristic protected by applicable law.
Please be aware that CorVel generally does not review all applications submitted in response to job openings posted on the Internet because of the large volume of responses.
Note to Employment Agencies: Please do not forward agency resumes. CorVel Corporation is not responsible for any fees related to unsolicited resumes.