RN Case Manager

Job Title

Experience: 3 years Required, Any Preferred Preferred Preferred Yes

Certs marked with * are preferred BLS Skills marked with * are preferred

Work Settings:

• Acute Hospital
• Long Term Acute Care/Rehab/Skilled Nursing

Case Management/Utilization Review:

• Admission Criteria
• Care coordination
• Discharge Planning
• Utilize InterQual Criteria
• Utilize Milliman Guidelines

Utilization Review:

• Admission Criteria Appeals and Denials
• Concurrent Review
• Continued Stay Reviews
• Medical Necessity
• Retrospective Review
• Utilize InterQual Criteria
• Utilize Milliman Guidelines

Regulatory:

• CMS: Centers for Medicare and Medicaid Services
• CPT (Current Procedural Terminology) coding and billing
• Department of Health
• DRG (Diagnosis Related Groups)
• HEDIS (The Healthcare Effectiveness Data and Information Set) Measures
• HIPAA guidelines (Health Insurance Portability and Accountability Act)
• ICD 10 Coding
• NCQA (National Committee for Quality Assurance)
• OSHA
• The Joint Commission/Core Measure/National Safety Goals
• Workers Compensation

Unit Details:

• Block
• Days: - Nights: - Weekends: -
• Yes Note: Within facility/scope of practice as needed