PRN, Utilization Review RN, Case Manager

Job Description

The Utilization Review RN, Case Manager (PRN ) collaborates with social workers, case managers, physicians, peers, and third-party payers to facilitate placement of patients in the appropriate level of care related to medical necessity. Responsible for timely provision/flow of specific clinical information to third-party payers to ensure authorization of stay. Position Highlights: • Shift Schedule: PRN (Variable Schedule) • Department: Care Coordination - Utilization Review What You’ll Need: • Graduation from accredited School of Nursing; BSN required. MSN preferred. • Registered Nurse licensure from the State of North Carolina Board of Nursing • Minimum 2 years of relevant clinical experience. Previous Utilization Review experience preferred. • Certification in Case Management highly recommended within 2 years of employment. Essential Functions: • Accurately conducts medical necessity reviews, utilizing the electronic medical record, in accordance with all state and federal regulations and the Utilization Management Plan. Demonstrates proficiency in applying nationally accepted evidence based criteria to assure appropriate hospital level of service. • Maintains timely and appropriate documentation of all utilization management activities. • Communicates information effectively, including comprehensive clinical information, to third-party payers, to secure timely authorization for the appropriate level of service. Provides payer feedback to case managers, social workers and providers. • Collaborates with Case Managers and Social Workers to provide information regarding payer criteria and resource availability, and to assist provider team with discharge planning. • Maintains current knowledge of state, federal and commercial payer requirements and guidelines. • Communicates with physician advisor and multi-disciplinary care team to ensure appropriate patient status based on medical necessity criteria and level of care. • Collaborates with payer, physician advisor and multi-disciplinary team to reconcile payer-issued denials. • Collaborates with physician adviser to identify medical necessity and level of care to ensure appropriate patient status. Communicates physician adviser determination to multidisciplinary team and payers. • Understands and maintains application of Medical Center Settings of Care. • Demonstrates knowledge of age/developmentally-appropriate patient care in accordance with Age-Specific Care Guidelines for the specific age groups served.

About Us

Atrium Health Wake Forest Baptist is a pre-eminent academic health system based in Winston-Salem, North Carolina. Atrium Health Wake Forest Baptist is part of Advocate Health, which is headquartered in Charlotte, North Carolina, and is the fifth-largest nonprofit health system in the United States, created from the combination of Atrium Health and Advocate Aurora Health. Atrium Health Wake Forest Baptist’s two main components are an integrated clinical system – anchored by Atrium Health Wake Forest Baptist Medical Center, an 885-bed tertiary-care hospital in Winston-Salem – that includes Brenner Children’s Hospital, five community hospitals, more than 300 primary and specialty care locations and more than 2,700 physicians; and Wake Forest School of Medicine, the academic core of Atrium Health Enterprise and a recognized leader in experiential medical education and groundbreaking research that includes Wake Forest Innovations, a commercialization enterprise focused on advancing health care through new medical technologies and biomedical discovery. Wake Forest Baptist Health, Wake Forest University School of Medicine and Atrium Health have joined forces in a strategic combination that will enhance care, transform medical education and create economic opportunity for countless lives in North Carolina and beyond. As a part of that combination, the two health systems will be integrating technology and platforms, including our career sites. This means that although you are applying on the Wake Forest Baptist Health Career Site, you receive communications from the Atrium Health Recruitment Team. Please know that this is an expected process, and thanks in advance for your flexibility. About The Team Mission, Vision and Culture Commitments Mission To improve health, elevate hope and advance healing – for all. Vision To be the first and best choice for care. Culture Commitments We create a space where all Belong We Work as One to make great things happen We earn Trust in all we do We Innovate to better the now and create the future We drive for Excellence – always Apply Job!