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RN Case Manager Pain and Wound Clinics

Licking Memorial Health Systems (LMHS) is a leading, non-profit healthcare organization, passionately dedicated to improving the health and well-being of our community.  With a history dating back to 1898, LMHS remains a cornerstone of healthcare excellence, catering to the evolving needs of Licking County. Our cutting-edge facility provides a comprehensive spectrum of patient care services, from life-saving emergency medicine to the comforting embrace of home healthcare, with a unique range of specialized medical services, including cancer, heart health, maternity, and mental wellness.

When you join the LMHS team, you become a vital part of your local community Hospital.  Working at LMHS is not just a job, it is a unique opportunity to directly impact the health and well-being of your friends, family, and neighbors.  You will be providing care in a place in which you are personally connected, where the impact of your work extends beyond the Hospital doors and into the heart of our community.  Our commitment to diversity, equity, and inclusion ensures that every member of our community is served with respect and compassion.  Join us in our mission – dedicated to patient safety, utilizing state-of-the-art technology, and with a passionate team of highly trained and compassionate individuals who strive to improve the health of the community.

Position Summary

The case manager/prior authorization RN reviews upcoming medical treatments, services, or procedures for the pain and wound clinic's patient populations to determine whether their procedure or therapy qualifies for insurance coverage.  The nurse assesses, evaluates, and provides recommendations to help ensure patients receive the services they need.  Responsible for working denial queues to facilitate resolution for denied claims. 

Responsibilities

• Accurate review of coverage benefits and payer policy limitations to determine the appropriateness of requested services.
• Works closely with pain, wound staff, and schedulers for upcoming patient procedures, rescheduled procedures, and denials.
• Follows up with patients as necessary.
• Performs timely prospective and retrospective reviews for services requiring prior authorization as well as timely concurrent review for continuation of care services. 
• follows the authorization process using established criteria as set forth by the payer or clinical guidelines.
• Works with the pain and wound providers to facilitate/participate in peer-to-peer reviews.
• Manages electronic work queues and documents detail as applicable in the medical record.
• Works closely with clinical staff, clinic providers, compliance, billing, and coding to ensure cases are authorized appropriately.
• Facilitates the completion of medical leave and disability paperwork for patients as necessary.  
• Completes Bureau of Workman’s Compensation (BWC) forms for patients as necessary.
• Assists patients with the appeal and denial process.
• Provides clinical information (utilization review) to external providers and managed care organizations.
• Participates in data collection for department dashboards.
• Coordinates insurance/patient’s condition changes with providers(s)/Physician’s Assistant as applicable.

Requirements

• Graduate from an accredited school of nursing and licensed in the state of Ohio.
• Previous case management, utilization review, or prior authorization experience preferred.
• Ability to carefully review medical records and ensure accuracy in data entry when providing information for prior authorization requests.
• Familiarity with electronic health records (EHR) and prior authorization platforms helpful.
• Excellent verbal and written communication skills
• Excellent computer skills.

Licking Memorial Health Systems is an equal opportunity employer and maintains compliance with all state, federal, and local regulations.  Licking Memorial Health Systems does not discriminate against applicants because of race, religion, color, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, family medical history or genetic information, political affiliation, military service, or other non-merit-based factors protected by law.