Case Manager – Utilization Management

Job not on LinkedIn

🔥 1 minute ago

🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

👔 Manager

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Lehigh Valley Health Network

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

Lehigh Valley Health Network is a comprehensive healthcare system that is now part of Jefferson Health, one of the top 15 not-for-profit health systems in the United States. It offers a wide range of medical services, including primary care, urgent care, and specialized institutes like the Lehigh Valley Topper Cancer Institute and the Lehigh Valley Heart and Vascular Institute. LVHN provides extensive care solutions, including video visits, second opinions, and a network of doctors and clinicians in numerous locations. It emphasizes education through residencies and fellowships and prioritizes patient-centric services such as lab testing and women's health care. The network also focuses on innovation, offering clinical trials and advanced therapies like CAR-T Cell Therapy.

📋 Description

• Review all hospitalized patients and evaluate admission appropriateness using approved criteria • Ensure appropriate inpatient or outpatient patient class assignment and compliance with third-party payer requirements • Educate staff on appropriate level-of-care assignment, patient class, and utilization management • Provide timely, accurate, and thorough clinical reviews for patient class decisions • Develop and implement methods, policies, and procedures to improve departmental efficiency • Partner with unit-based care managers regarding patient financial status, diagnosis, and discharge needs • Coordinate with precertification, appeals, patient access, billing, coding, and finance teams • Assess admission appropriateness using evidence-based criteria • Collaborate on complex cases, patient class assignment, and reimbursement optimization • Complete patient class changes as directed by physician advisors, attending providers, and payers • Document authorizations and downgrades • Participate in performance improvement assessment, implementation, and evaluation

🎯 Requirements

• Specialized Diploma in nursing • 2 years of previous utilization review experience • 2 years of knowledge of utilization management as it relates to third party payers • Ability to maintain strict HIPAA adherence and confidentiality of all PHI • Ability to work in a team environment and demonstrate flexibility • Attention to detail and positive attitude • Ability to complete assignments accurately and timely while managing multiple responsibilities • Proficiency with all work queue processes • Knowledge of evidence-based clinical decision support criteria • RN - Licensed Registered Nurse, State of Pennsylvania, upon hire • Preferred: Bachelor’s Degree in nursing • Preferred: Knowledge of InterQual and/or MCG criteria • Preferred: ACM, ACMA, CCM, and/or CMCN certifications in Pennsylvania upon hire

🏖️ Benefits

• Full-time employment • Day shift schedule • Remote work in Pennsylvania • Equal employment opportunity • 8-hour Monday–Friday work schedule with weekend and holiday coverage