Veracity Software Inc
Utilization Review / Case Manager (RN)
Veracity Software Inc, Chicago, Illinois, United States, 60290
Title:
Utilization Review / Case Manager (RN) Location:
Chicago, Illinois Reports To:
Clinical Director, Behavioral Health Services Term:
Permanent, Full-time General Summary
The Utilization Review/Case Manager facilitates appropriate use of hospital resources by ensuring that patients meet acute inpatient criteria and anticipates discharge needs in a timely manner. The role acts as a central communicator with external and internal customers, collaborating with social workers, case managers, vendors, payers, and community agencies. Key Responsibilities
Utilization Management
Perform inpatient utilization management per plan, payer requirements, and standards. Collaborate with physicians and healthcare team members for timely and appropriate patient management. Collect and document clinical data to support admission and continued hospitalization. Provide accurate clinical information to payers as required. Support DRG Assurance Program with accurate data collection and assignment. Perform non-acute profiling, collect data on avoidable days, and refer cases to Physician Advisor when needed. Discharge Planning
Participate in family meetings and care conferences. Ensure timely referrals for discharge planning and use of regional/community resources. Refer complex cases to Social Services as appropriate. Ensure psychological needs of patients are met via direct intervention or referral. Communication & Coordination
Act as a central communicator with patients, families, vendors, payers, and hospital staff. Provide continuity of care by leveraging community resources and maintaining updated resource manuals. Refer cases not meeting criteria to Physician Advisor in a timely manner. Follow up with Medical Director/Physician Advisor on unresolved issues. Other Duties
Maintain safe patient care environment and infection control compliance. Manage departmental operations (phones, supplies, data tracking). Attend in-service presentations and complete all mandatory education. Perform other duties as assigned. Knowledge, Skills & Abilities
Graduate of an accredited school of nursing (Required) Current RN License in Illinois (Required) 2+ years relevant clinical experience (Preferred) Utilization management experience (Preferred) Knowledge of Medicare/Medicaid, Managed Care, and Commercial insurance processes (Preferred) Strong written/oral communication skills with appropriate grammar and vocabulary Proficiency in Microsoft Word and Excel (Required) Ability to provide excellent customer service at all times Ability to anticipate and coordinate multiple functions effectively
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Utilization Review / Case Manager (RN) Location:
Chicago, Illinois Reports To:
Clinical Director, Behavioral Health Services Term:
Permanent, Full-time General Summary
The Utilization Review/Case Manager facilitates appropriate use of hospital resources by ensuring that patients meet acute inpatient criteria and anticipates discharge needs in a timely manner. The role acts as a central communicator with external and internal customers, collaborating with social workers, case managers, vendors, payers, and community agencies. Key Responsibilities
Utilization Management
Perform inpatient utilization management per plan, payer requirements, and standards. Collaborate with physicians and healthcare team members for timely and appropriate patient management. Collect and document clinical data to support admission and continued hospitalization. Provide accurate clinical information to payers as required. Support DRG Assurance Program with accurate data collection and assignment. Perform non-acute profiling, collect data on avoidable days, and refer cases to Physician Advisor when needed. Discharge Planning
Participate in family meetings and care conferences. Ensure timely referrals for discharge planning and use of regional/community resources. Refer complex cases to Social Services as appropriate. Ensure psychological needs of patients are met via direct intervention or referral. Communication & Coordination
Act as a central communicator with patients, families, vendors, payers, and hospital staff. Provide continuity of care by leveraging community resources and maintaining updated resource manuals. Refer cases not meeting criteria to Physician Advisor in a timely manner. Follow up with Medical Director/Physician Advisor on unresolved issues. Other Duties
Maintain safe patient care environment and infection control compliance. Manage departmental operations (phones, supplies, data tracking). Attend in-service presentations and complete all mandatory education. Perform other duties as assigned. Knowledge, Skills & Abilities
Graduate of an accredited school of nursing (Required) Current RN License in Illinois (Required) 2+ years relevant clinical experience (Preferred) Utilization management experience (Preferred) Knowledge of Medicare/Medicaid, Managed Care, and Commercial insurance processes (Preferred) Strong written/oral communication skills with appropriate grammar and vocabulary Proficiency in Microsoft Word and Excel (Required) Ability to provide excellent customer service at all times Ability to anticipate and coordinate multiple functions effectively
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