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. This position fully remote, 40h/week, Monday - Friday with intermittent coverage for alternating schedule of Tuesday - Saturday.
CorVel is a national provider of industry-leading risk management solutions for the workers' compensation, auto, health and disability management industries. CorVel was founded in 1987 and has been publicly traded on the NASDAQ stock exchange since 1991. Our continual investment in human capital and technology enable us to deliver the most innovative and integrated solutions to our clients. We are a stable and growing company with a strong, supportive culture and plenty of career advancement opportunities. Over 3,500 people working across the United States embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!).
A comprehensive benefits package is available for full-time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off.
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.