Supports and promotes the mission and values of Covenant Health Ministry.
Conducts admission, continued stay, and retrospective medical necessity reviews using health system approved criteria.
May communicate with payor representatives regarding patients’ level of care and regarding plans for discharge.
Responsible for communicating and collaborating with internal departments (such as patient registration, patient accounts and others), as appropriate, to verify payer source as soon as possible upon the decision that the patient is to receive services.
Perform ongoing evaluation and critical analysis of the patient’s progress to ensure that the patient’s hospital needs are being delivered in the most appropriate setting and in a timely manner.
Seeks peer assistance and/or provides consultation regarding complex cases and/or cases that have deviated from the initial plan of care.
Facilitates education of the interdisciplinary team related to the individual patient case management goals, InterQual criteria and coverage determinations, multi‑system disease processes, and payor criteria.
Identifies opportunities for improvement in processes and quality of care and communicates findings to the director of the department.
Maintains current knowledge of DNV & CMS regulations.
Identifies cases in which a Hospital‑Issued Notice of Noncoverage (HINN) or Advanced Beneficiary Notice (ABN) is warranted.
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 UM 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.
Identifies and tracks delays in care / services, inappropriate admissions, and unnecessary continued days by utilization of avoidable day tracking in the electronic medical record.
Develops and maintains professional relationships with department team members and members of the medical staff.
Participates in assigned committees and reports out any significant changes or new information to the team.
Participates in activities that increase professional / clinical skills.
Demonstrates a commitment to maintain competencies and participates in those activities, which contribute to the ongoing development of self, the profession, and other members of the health care team.
Annual goals are achieved.
Attends pertinent case management / utilization review programs to maintain current knowledge of UR practices.
Acts as a role model for other case managers.
Maintains current knowledge of organizations’ policies and procedures.
Maintains / enhances professional development / skills required to function as a Utilization Review Case Manager.
Completes all mandatory learning assignments within specified timeframes.
Coordinates special projects as requested.
Other duties as consistent with this role.
Job Requirements
Ability to manage time wisely and focus on tasks without distraction.
Ability to work autonomously in an organized manner.
Strong organizational and time management skills.
Professional skills in human relations and teamwork.
Excellent communication skills are needed.
Good computer skills are needed.
Ability to work remotely as needed.
Education and Experience
Registered Nurse licensed in New Hampshire required.
Minimum of five years broad clinical experience preferred.
Case management and/or Utilization Management experience is preferred.
Certification as CCM or ACMA‑RN preferred.
Covenant Health Mission Statement
We are a Catholic health ministry, providing healing and care for the whole person, in service to all in our communities.
Our Core Values
Compassion – We show respect, caring, and sensitivity towards all, honoring the dignity of each person, especially the poor, vulnerable, and suffering.
Integrity – We promote justice and ethical behavior, and responsibly steward our human, financial and environmental resources.
Collaboration – We work in partnership, dialogue and shared purpose to create healthy communities.
Excellence – We deliver all services with the highest level of quality, while seeking creative innovation.
Applicants, employees and former employees are protected from employment discrimination based on race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age (40 or older), disability, and genetic information (including family medical history).
Comp Range
$33.43 – $50.15
Rate of pay displayed reflects the beginning of the pay scale. At the time of an offer, determination of your offer will reflect your skills and experience as it relates to the position.