The Utilization Review Case Manager gathers demographic and clinical information on prospective, concurrent and retrospective in-patient admissions and out-patient treatment, certifies the medical necessity and assigns an appropriate length of stay while supporting the goals of the Case Management department and of CorVel.
This is a remote position
Essential Functions & Responsibilities
- Identifies the necessity of the review process and communicates issues of concern to the appropriate claims staff/customer
- Collects data and analyzes information to make decisions regarding certification or denial of treatment
- Documents all work in the appropriate manner
- Promotes utilization review services with stakeholders
- Complies with all safety rules and regulations during work hours in conjunction with the Injury and Illness Prevention Program (IIPP)
- Additional duties as assigned
Knowledge & Skills
- Must have thorough knowledge of both CPT and ICD coding
- Ability to interface with claims staff, attorneys, physicians and their representatives, as well as advisors/clients and coworkers
- Effective organization skills in a high-volume, fast-paced environment
- Strong time management skills with the ability to meet designated deadlines
- Excellent written and verbal communication skills
- Ability to work both independently and within a team environment
- Strong interpersonal skills
- Ability to utilize Microsoft Office including Excel spreadsheets
- Knowledge of the workers' compensation claims process preferred
- Knowledge of outpatient utilization review preferred
Education & Experience
- Graduate of accredited school of nursing with an associate's degree, Bachelor of Science degree or Bachelor of Science in Nursing
- Current Nursing licensure in the state of operation required; RN is required unless local state regulations permit LVN/LPN
- 4 or more years of recent clinical experience
- Prospective, concurrent, and retrospective utilization review experience preferred
- Experience in the clinical areas of OR, ICU, CCU, ER and/or orthopedics preferred
Pay Range: $32.18 - $48.68 per hour