Utilization Review Case Manager

Location: Maestro Consulting Services, Lincolnwood, IL
Date Posted: 06-06-2018

Maestro Consulting Services provides consulting services to the member facilities of the Symphony Post Acute Network www.symphonypan.com.  The member facilities are short & long-term care skilled nursing facilities and assisted living communities.  We are committed to being the Employer of Choice and looking for someone who is dedicated and committed to a long-term career with our organization.  The current team is a very cohesive group of respectful, loyal, hard-working employees and someone joining the team must embody the same qualities.  This is not just a position, it is career.  There are multiple opportunities for future growth within the financial and clinical consulting service teams.

The Utilization Review Case Manager will be responsible for facilitating coordination of care across the continuum of the patient’s stay from admission to discharge. Shift/Hours: 8:30am – 5:00pm preferred/ 40 hours per week and located at 7373 N Lincoln Ave, Lincolnwood, IL 60712

The Sub Acute - Skilled Nursing Facility Case Manager will be responsible for the following:
  • Manage the accounts of patients who present with a Managed Care payor (PPO, POS, EPO, HMO and Medicare Advantage Plans) to Symphony Post Acute Member Facilities.
  • Verify, interpret and apply patient’s benefits as it relates to Skilled Nursing.
  • Verify patient’s clinical and current/prior level of functions (ADL’s and FIMS scores) for determination if admission to a Sub Acute Skilled Nursing Facility will meet Managed Care/Payor’s requirements (InterQual and Milliman Care Guidelines).
  • Obtaining pre-certification and authorizations to admit patients to ensure approval and financials.
  • Ability to compare reimbursement per Contract terms vs. cost of patient to perform ROI component.
  • Review and submission of Concurrent reviews with the Managed Care Payor’s Case Managers.
  • Obtain status on patient’s care and identify variances to ensure appropriateness of length of stay per Managed Care/payor’s protocols.
  • Consult on Discharge Planning/Transition of Care appropriateness for the patient based on managed care/Payor’s requirements.
  • Communicate continued stay matters and complex cases with internal staff and Managed Care Payor’s Case Managers.
  • Provide Multidisciplinary Team (Clinical, Therapy, Social Services, Admissions, Business Office, and Billing) with Managed Care information to facilitate protocols/outcomes for Managed Care patients.
  • Ability to understand, interpret and apply managed care payor contracts for the appropriate leveling of patient for reimbursement and any carve-out/stop loss clauses.
  • Completion of monthly Billing Log to Billing Department per defined time.
  • Assist Corporate Billing Department with billing issue on behalf of patients/members.
  • Utilize trend data to identify and evaluate effectiveness of delivery system.
Skills, Knowledge and Abilities Required:
  • Self Starter and results orientated personality
  • Strong organizational, planning and problem-solving skills
  • Strong Customer Service skills
  • Ability to build and maintain working relationships with Managed Care Payor’s Case Managers, Internal Staff.
  • Highly knowledgeable in Case Management practices/protocol (InterQual & Milliman Care Guidelines)
  • Highly knowledgeable in Managed Care Delivery Systems
  • Ability to read, understand, interpret and apply Contract/Level of Care (per diem) and exclusion components/rates within each Managed Care Contract to maximize reimbursement
  • Ability to complete all necessary Managed Care forms/reports
  • Ability to communicate professionally and effectively with internal and external customers
  • Ability to be pro-active and contribute to the Team and Organization improvement
  • Mathematical abilities
  • Proficient in Outlook, Microsoft Word and Excel
  • Ability to work in Point Click Care/Electronic Medical Records (EMR)
Education/Experience
  • Bachelor’s Degree in one of the following:
    • Bachelor of Nursing, BSN
    • Human Services
    • Business Administration
    • Social Work
  • 3-5 year experience in post-acute care ideally with case management experience
Employee Benefits:
  • Variety of health, dental and vision benefits
  • Wellness Program – 25% reimbursement of employee only health insurance deduction
  • Voluntary benefits offered via payroll deduction and guaranteed issue for new hires
  • Generous vacation time, sick days, personal days, holidays and much more
  • 401k plan with 10% employer match
  • Continuing education and tuition reimbursement for programs related to position
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