GENERAL SUMMARY: RN Under general supervision, registered nurse performs a variety of reviews and applies utilization and case management techniques to determine the most efficient use of resources to support the provision of appropriate, cost effective and quality health care. Provides leadership in the integration of utilization management principles throughout the System.
DUTIES AND RESPONSIBILITIES: The following are essential job accountabilities: 1 Performs initial reviews for medical necessity and appropriateness of setting for the assigned case load. 2 Conducts concurrent reviews to ensure medical necessity for continued hospitalization and initiates problem-solving techniques as needed to prevent over and/or under utilization. 3 Liaisons between third party payors and the treatment team regarding the identified treatment plan in accordance with contractual guidelines or System policy. 4 Assists the patient care team with the identification and coordination of alternative treatment settings which will provide appropriate care, maintain quality of care and reduce cost. 5 Identifies conditions which require case management across the continuum. Collaborates with the members of the patient care team to identify interdisciplinary needs. 6 Assists with the collection and analysis of utilization patterns and denied cases. 7 Brings known or suspected problems of under-, over-, or inappropriate utilization of resources to the attention of the appropriate manager(s). DEPARTMENT DESCRIPTION:
WellSpan Population Health Services provides coordination of health benefits offering a Preferred Provider Organization supporting accountable care and medical management which includes case management and utilization management. WellSpan Population Health Services is committed to provide care in compliance with the WellSpan triple aim: to improve the cost, quality, and patient experience in an efficient and effective delivery system for patients and providers.
Required Skills
2 - 3 years of acute care RN work experience
Utilization management, case management, or clinical nursing specialty expertise
Requires payer utilization, case management, and appeals experience
Active PA RN license required
Strong PC skills
Strong communication skills
Must be able self directed and autonomous in work habits
Detail-oriented
Required Experience
Full time (80 hours biweekly)
Mon-Fri
day shift
telephonic/remote position- must be within commutable distance to York offices, in home/onsite visits monthly
2 - 3 years of acute care RN work experience
Utilization management, case management, or clinical nursing specialty expertise
Requires payer utilization, case management, and appeals experience
Active PA RN license required
Strong PC skills
Strong communication skills
Must be able self directed and autonomous in work habits
Detail-oriented