- Is knowledgeable and compliant with all regulatory and statutory regulations that pertain to UR and self-insured clients, especially ERISA, HIPAA and Workers’ Compensation
- Provides and facilitates utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines
- Interacts telephonically with employers, employees/ patients, physicians and facilities to determine medical status, type of care needed (surgery, hospitalization and/or physical therapy) and future care needs.
- Facilitates and expedites discharge planning.
- Maintains accurate records of individual cases.
- Evaluates needs for alternative treatment as required.
- Ensures each case provides optimal medical care that is cost effective.
- Is kind, caring, sympathetic and positive with all customers and fellow employees.
- Adheres to established quality assurance standards and all MagnaCare policies and procedures.
- Discusses and documents any concerns, complaints and/or issues with direct supervisor or may report any issues related to job to Human Resources or the CMO if the UR manager is not available, not appropriate for this action or has not responded to employees concerns in a timely manner.
- Participates in QA activities for up to 10% of employed time.
Required Skills and Experience:
- Currently licensed Registered Nurse (RN) or Licensed Practical Nurse (LPN) with licensure in the state of employment ( New York State ).
- Must maintain current licensure(s) and specialty certifications that are relevant to this position.
- Bachelor’s degree preferred.
- Minimum of 4 years experience in a clinical environment required.
- Previous experience in case management preferred.
- Strong skills in medical assessment/medical record review.
- Excellent customer service skills.
- Ability to define and solve problems, collect data, establish facts and make effective decisions a must.
- Ability to work proficiently on a computer (PC) with working knowledge of Microsoft Word and Excel.
- Ability to work in a database environment a plus.
Magnacare is a Fully Integrated Healthcare Services Delivery System servicing clients with over $1.3 billion in annual healthcare spending. The company was founded in 1990 on the principle of providing affordable, high-quality health care programs with the emphasis on customer service. MagnaCare services the New York and New Jersey Metropolitan area where we represent over 650,000 lives with a healthcare delivery system consisting of approximately 47,000 multi-specialty physicians and includes most major hospitals.