Utilization Review Case Manager - Stony Brook Medicine : Job Details

Position Summary The purpose of this position is to provide quality concurrent review to screen patients for level of care i.e. Inpatient, Observation, Emergency and other Outpatient services. This position also requires the candidate to conduct concurrent and retrospective chart reviews for potential verbal or written appeal of days denied for all payers including commercial, government and external denials.Qualified candidates will demonstrate superior patient care experience and possess outstanding communication skills while adhering to high standards of care.Duties of a Utilization Review and Appeals Case Manager may include the following but are not limited to:

• Provide Utilization Review Screens for Short Stay and Observation Reviews, which includes inpatient stays less than 72 hours.
• Provide Utilization Review for the Emergency Room and all inpatient units as needed.
• Review Observation cases and provide appropriate documentation.
• Review Medicare and Medicaid Cases.
• Follow the process for Condition 44 on all Medicare cases.
• Follow the process for change of inpatient to outpatient status on all payers excluding Medicare.
• Document avoidable delays and days.
• Conduct Retrospective review for potential verbal or written appeal of all denied cases. This process may include communication with the Attending MD if the patient is still hospitalized.
• Participate proactively and collaboratively to reduce denials and enhance reimbursement.
• Document and maintain data to identify and analyze patterns, trends and solutions on all denial activity.
• Promote continuous quality improvement on identified issues.
• Promote efficient use of hospital resources.
• Collaborate with the interdisciplinary team on all complex cases.
• Maintain high customer service at all times.

Qualifications Required:

• NY RN License.
• Bachelor's Degree.
• Three to Five years RN experience in an Acute Care Hospital.
• Working knowledge of MCG or Interqual.
• Knowledge of Regulatory agencies and standards of care.
• Computer Skills in Word, Excel and PowerPoint.
• Excellent Communication Skills. Creative, flexible, professional and courteous.
• Weekday and weekend flexibility.

Preferred:

• Master's Degree.
• Experience or Certified in Case Management, Quality, Risk, MCG, CDI or Utilization Management.
• PRI certified.
• Demonstrate experience in Appeal and Denial writing.
• Proficient in Word and Excel and other computer skill sets.
• Experience with Psychiatry, Pediatrics or Neonatal Care. Coding Experience.
• Bilingual.

Special Notes:Resume/CV should be included with the online application. Posting Overview:This position will remain posted until filled or for a maximum of 90 days. An initial review of all applicants will occur two weeks from the posting date. Candidates are advised on the application that for full consideration, applications must be received before the initial review date (which is within two weeks of the posting date). If within the initial review no candidate was selected to fill the position posted, additional applications will be considered for the posted position; however, the posting will close once a finalist is identified, and at minimal, two weeks after the initial posting date. Please note, that if no candidate were identified and hired within 90 days from initial posting, the posting would close for review, and possibly reposted at a later date.

• Stony Brook Medicine is a smoke free environment. Smoking is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises.
• All Hospital positions maybe subject to changes in pass days and shifts as necessary.
• This position may require the wearing of respiratory protection, which may prohibit the wearing of facial hair.
• This function/position maybe designated as essential. This means that when the Hospital is faced with an institutional emergency, employees in such positions may be required to remain at their work location or to report to work to protect, recover, and continue operations at Stony Brook Medicine, Stony Brook University Hospital and related facilities.

Prior to start date, the selected candidate must meet the following requirements:

• Successfully complete pre-employment physical examination and obtain medical clearance from Stony Brook Medicine's Employee Health Services*
• Complete electronic reference check with a minimum of three (3) professional references.
• Successfully complete a 4 panel drug screen*
• Meet Regulatory Requirements for pre employment screenings.
• Provide a copy of any required New York State license(s)/certificate(s).

Failure to comply with any of the above requirements could result in a delayed start date and/or revocation of the employment offer. *The hiring department will be responsible for any fee incurred for examination.Stony Brook University is committed to excellence in diversity and the creation of an inclusive learning, and working environment. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, pregnancy, familial status, sexual orientation, gender identity or expression, age, disability, genetic information, veteran status and all other protected classes under federal or state laws.If you need a disability-related accommodation, please call the University Office of Equity and Access at (631)###-####. In accordance with the Title II Crime Awareness and Security Act a copy of our crime statistics can be viewedhere. Visit ourWHY WORK HERE page to learn about the total rewards we offer. Stony Brook University Hospital, consistent with our shared core values and our intent to achieve excellence, remains dedicated to supporting healthier and more resilient communities, both locally and globally.Anticipated Pay Range: The salary range (or hiring range) for this position is $95,795 - $114,484 Base/ year. The above salary range represents SBUH's good faith and reasonable estimate of the range of possible compensation at the time of posting.The specific salary offer will be based on the candidate's validated years of comparable experience.Any efforts to inflate or misrepresent experience are grounds for disqualification from the application process or termination of employment if hired. Some positions offer annual supplemental pay such as:

• Location pay for UUP, CSEA & PEF full-time positions ($3400)
• Night shift differential ($15,000), evening shift differential ($10,000)
• Inconvenience pay/supplemental shift differential. ($575)

Your total compensation goes beyond the number in your paycheck. SBUH provides generous leave, health plans, and a state pension that add to your bottom line.