Managed Care Team Lead
: Job Details :

OverviewRemote or Hybrid with Experience - Based Off Of LocationInsurance Managed Care RN - Case ManagerFull-Time; Monday-Friday; 8:00am-5:00pmRock Island, IL* Seeking candidate with insurance experience on the company side*The Managed Care RN Utilization/Case Manager, under the direction of the Director of Managed Care serves a key role in coordinating the patient's/enrollees interdisciplinary providers/services to assess and effectively use resources and to track and minimize the inappropriate use of such resources while providing the right care at the right level at the right time. This role is responsible for utilization management and case management for patients/enrollees. This includes payment authorizations, clinical coordination, integration and facilitation of all care and services for the patient by all members of the health care team.This role performs admission assessment, continued stay reviews all according to established criteria of third party carriers, and as found necessary on cases with third party payor review. Monitoring of plan of care to address physical and psychosocial needs, and provide problem solving assistance. Coordinates services, discharge planning, referrals to appropriate community agencies and assists with Advance Directives when appropriate. Responsible for reviewing and updating critical paths with healthcare team when applicable. Also, assessing, monitoring, analyzing and documenting resources utilized in the provision of patient care.Why UnityPoint Health?* Commitment to our Team - For the third consecutive year, we're proud to be recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare for our commitment to our team members.* Culture - At UnityPoint Health, you matter. Come for a fulfilling career and experience a culture guided by uncompromising values and unwavering belief in doing what's right for the people we serve.* Benefits - Our competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you're in.* Diversity, Equity and Inclusion Commitment - We're committed to ensuring you have a voice that is heard regardless of role, race, gender, religion, or sexual orientation.* Development - We believe equipping you with support and development opportunities is an essential part of delivering a remarkable employment experience.* Community Involvement - Be an essential part of our core purpose-to improve the health of the people and communities we serve.Visit to hear more from our team members about why UnityPoint Health is a great place to work.Responsibilities* Performs utilization and case management reviews using established criteria to confirm medical necessity, appropriate level of care and efficient use of resources and payment approval.* Requests reviews with physician advisors, and/or Executive Health Resources (EHR), as appropriate, if admission or continued stay criteria are not met, assuring appropriate and timely level of care status.* Conducts payment authorizations and coordinated payment denials while meeting timeliness guidelines.* Ensures case coordination with client's health care providers.* Provides utilization management and case management to designated enrollees. Assuring that all enrollees receive clinically sound triage/referral and ongoing care management services for medical needs.QualificationsEducation:* Registered Nurse* CCM (Certified Case Manager)Experience:* 5+ years of nursing experience* Insurance experience on the company sideLicense(s)/Certification(s):* Unrestricted Nurse licensed / or licensed behavioral health clinician. Required Illinois and Iowa licenses within first 90 days of hireKnowledge/Skills/Abilities:* Professional Communication - written & verbal* Customer/patient focused* Self-motivated* Managing priorities/deadlines* Flexibility to adapt to changing priorities or needs* Planning and organizing skills* MS Office proficiency (Outlook, Word)* Ability to give work direction to non-clinical staff#RYCJessi* Area of Interest: Nursing;* FTE/Hours per pay period: 1.0;* Department: Prec Carve Out;* Shift: 8:00am to 5:00pm Monday through Friday;* Job ID: 146644;