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Access Case Manager-RN - Utilization Management

2131 South 17Th Street
Wilmington, NC
Job ID: 4768
Date Posted: Sep 30, 2021

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Job Description



NHRMC, established in 1967 in Wilmington, NC, is recognized as a preeminent healthcare organization focused on leading our community to outstanding health. We have an 855 bed network of hospitals and multi-specialty physician group practices with more than 200 physicians. With a network of primary, specialty, neighborhood clinics and regional medical centers; you will find our culture is the very definition of best in practice. Join us and find out how many ways NHRMC offers you the chance to focus on what really matters - our patients and community.

About the Job

Location: New Hanover Regional Medical Center

Department: Utilization Management

Full Time Equivalent: FTE: 1.000000

Work Type: 64 to 80 Hours Pay Period

Work Schedule: 8HR DAY 

Exempt from Overtime: Exempt: Yes

What You'll Do

The Access Case Manager is a professional Registered Nurse with strong clinical knowledge and leadership skills who works under the supervision of the Manager. The Access Case Manager Collaborates with Utilization Management Physician Advisor (UMPA) to ensure that patient status and level of care ordered by the provider meets payor rules and regulations and that provider documentation of medical necessity supports the patients status and level of care. Access CM also collaborates with physicians and the interdisciplinary team to coordinate and monitor the provision of cost-effective care in the most clinically appropriate setting, ensuring quality health care services and resources.

1. Utilizes developmentally appropriate medical necessity criteria to perform timely admission review in order to determine appropriateness & medical necessity for hospital care and patients status.
2. Issues beneficiary notices related to hospital coverage in collaboration with the UMPA.
3. Assists the physicians in identifying alternatives to admission for cases that do not require acute care.
4. Educates physicians to insure compliance with the Utilization Management Plan for the hospital.
5. Assists staff in clinical decision making and priority setting to ensure an optimal hospital length of stay
6. May assist with care for a defined patient population to assure optimal outcomes including appropriate LOS, cost containment, and customer satisfaction.
7. Educates the patient/family, and care providers regarding regulations related to medical necessity and insurance criteria for payment of hospital care.
8. Maintains awareness of current reimbursement issues as they relate to the patient population.
9. Notifies beneficiary of change to out patient status based upon UMPA decision as appropriate.
10. Participates in performance improvement activities based on the patient population by identifying barriers to care, systems and process issues, and contributing to data collection and analysis for improvement plans.
11. Develops collaborative relationships with other departments, entities, and external health care agencies to facilitate and support quality of care.
12. Demonstrates strong communication skills that are effective in working with a variety of persons, including the patient, public, coworkers, guests, payers, outside agencies and medical staff.
13. Acts as a clinical/educational resource for patients, families, interdisciplinary team members and payers.
14. Organizes and performs work responsibilities effectively and efficiently.

Position Requirements

* Registered Nurse

* Associate Degree

Other information:
Experience: Minimum of 5 years experience as an RN required. Must be able to demonstrate expertise in a clinical specialty for defined patient population. Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.
Performs other duties as assigned.
Individual will possess commensurate combination of education, experience and qualifications.

Other Information

This position description has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications which may be required of the employee assigned to the position. Depending on the location of the job, duties may vary. Receipt of the job description does not imply nor create a promise of employment, nor an employment contract of any kind; my employment with the Company is at will.

  • Member Top 100 Hospitals – In 2016 NHRMC was recognized as a Top 100 Hospital demonstrating significant investment and financial sustainability for the communities we serve. 
  • Newsweek's 2020 list of Best Maternity Care Hospitals - NHRMC Betty H. Cameron Women's & Children's Hospital was named as a Best Maternity Care Hospital by Newsweek. 
  • Forbes America’s Best Large Employers 2018 and 2019Link 
  • Becker’s 150 Top Places to Work in HealthcareLink 
  • Healthgrades Outstanding Patient Experience

Consider a career at NHRMC and become part of this award winning team!

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