Summary The UR Case Manager conducts medical necessity reviews per the Utilization Management (UM) plan for patients housed on a nursing unit, including inpatient admissions, patients on observation, and outpatients in a bed. The UR Case Manager identifies delays in care and documents and communicates findings with the care team and the payor, when necessary. The UR case manager also acts as an advocate for the patient and assists in providing information regarding their insurance coverage. Essential Duties and Responsibilities + Supports and promotes the mission and values of Covenant Health Ministry. + Conducts admission, continued stay, and retrospective medical necessity review using health system-approved criteria. + Identified cases in which a hospital –Issued Notice of Noncoverage (HINN) or Advanced Beneficiary Notice (ABN) in collaboration with the Utilization Review Manager. + Documents outcome of review and communicates findings rapidly and accurately, assuring an appropriate order is obtained, when necessary. + Ensures payers receive complete and accurate clinical information to support assigned level of care and hospital status, as necessary, and documents as per department guidelines. + Follows established UR processes for patients not meeting criteria by utilizing second-level review / Physician Advisor services. + Identifies opportunities for physician peer-to-peer reviews when adverse determinations are received. + Develops and maintains professional relationships with department team members and the medical staff. + Participates in activities that increase professional/clinical skills. + Completes all mandatory compliance courses and competencies on time. + Ability to manage time wisely, work autonomously, and focus on tasks without distraction. + Maintains all required competencies and completes annual compliance courses on time. + Other duties as consistent with this role. Job Requirements Job Knowledge and Skills + Proficient in Microsoft Office. + Strong verbal and written communication skills. + Strong interpersonal skills. + Ability to work within a stressful, fast-moving environment. + Knowledge of community agencies and resources preferred. + Knowledge of third-party payer system. Education and Experience + Bachelor’s degree required. + Active State of Maine RN license. + Minimum of three years’ experience in utilization review, discharge planning, social work case management, or Utilization Manager experience preferred. + Certification as CCM or ACMA-RN preferred.