Job Description

The Utilization Review RN Case Manager applies knowledge of medical necessity criteria and regulatory requirements in determining the appropriate patient status for any person destined for a bed on the patient care units. This position works closely with admitting and attending providers as well as the Utilization Management Physician Advisor to ensure patient status is accurate and compliant with regulatory standards. The Utilization Review RN Case Manager is viewed by clinical teams as an expert in the building when it comes to selecting the appropriate level of service for patients. They participate in multidisciplinary discharge rounds on the hospital units to understand clinical course, discharge plans and possible changes in medical necessity, all toward selecting the levels of care that match clinical necessity. This position plays an essential role in securing reimbursement to the hospital for services provided by commercial, Medicaid and Medicare payers through timely communication and submission of relevant clinical information to the payer when required. The effective tending of utilization review lowers the frequency of avoidable denials by payers for services provided. This role ensures adherence to the policies and guidelines of all payer review organizations to secure appropriate reimbursement for patient hospitalizations. During normal business hours this position may screen patients to determine if case management follow-up is required.

Minimum Qualifications

• Bachelor of Science in Nursing
  OR
• Associate’s degree in Nursing PLUS three years of experience as an RN
• Registered nurse license in the Commonwealth of Virginia or from a state that is part of a compact agreement with Virginia
• Acute care hospital experience or comparable job-related experience in at least 3 of the last 5 years

Preferred Qualifications

• National certification in case management or utilization management preferred
• 3 to 5 years of recent experience in utilization review and/or discharge planning in an acute care setting preferred

Skills

• Comprehensive knowledge of regulatory, legislative, and DNV standards related to utilization review.
• Proficient in computer skills including navigating EHRs, medical necessity criteria, Microsoft Office products.
• Effective verbal and written skills with the ability to collaborate with multiple disciplines throughout the organization.
• Good problem solving and decision-making skills.
• Excellent organizational skills and the ability to work in a fast-paced environment.

Some benefits of working at Augusta Health include

• Healthcare Benefits
• Generous paid time off
• Retirement savings helping you to plan for your future
• Free onsite parking
• 24/7 armed security to ensure your safety
• Tuition reimbursement
• Onsite child care
• Augusta Health Fitness Reimbursement Program
• Onsite credit union
• Employee discounts including the cafeteria, gift shop, pharmacy, and movie tickets

Company Information

Augusta Health is a mission-driven, independent, nonprofit, community health system located in Fishersville Virginia in Virginia’s scenic Shenandoah Valley. Augusta Health offers a full continuum of inpatient and outpatient which includes Augusta Medical Center a 255 bed inpatient facility and Augusta Medical Group which is comprised of 40 practice locations and four urgent care locations.

Equal Opportunity

Augusta Health recruits, hires and promotes qualified candidates for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex (including pregnancy), sexual orientation, veteran or military discharge status, and family medical or genetic information.