Concurrent Review Case Manager

Your Future is our Future

At Lumeris, we believe that our greatest achievements are made possible by the talent and commitment of our team members. That's why we are actively seeking talented and collaborative individuals who are passionate about making a difference in the healthcare industry. Join us today as we strive to create a system of care that every doctor wants for their own family and become part of a community that values its people and empowers you to make an impact.

Position:Concurrent Review Case Manager

Position Summary:In this role, you will play a vital part in ensuring our members receive the right care at the right time. You will conduct clinical reviews of inpatient and outpatient services to assess medical necessity and appropriate length of stay, aligning decisions with departmental standards and Medicare guidelines.
Beyond clinical review, you will collaborate closely with inpatient case managers, physicians, and community resources to support seamless care transitions. Through proactive discharge planning and care coordination, you will help guide members safely between care settings while promoting high-quality, cost-effective outcomes.

Job Description:

Primary Responsibilities

• Performs pre-service and concurrent reviews of requested services within specified department timelines. In-Patient reviews include Acute Facilities and Skilled Nursing Facilities. Out-Patient reviews include service authorizations and home health care.
• Applies clinical knowledge for the interpretation and evaluation of clinical data to ensure compliance with established criteria.
• Reviews authorization requests for services according to adopted Plan and InterQual criteria.
• Reviews questionable cases with facility team members and the Medical Director to assess if care requested meets medical necessity criteria.
• Documents denial process and provides timely provider and member notification following specified timelines and department protocols.
• Initiates early discharge planning, incorporating transition of care plans, with facility team members and plan's primary care providers. 
• Initiates and coordinates facility transfers, incorporating transition of care plans. 
• Coordinates with appropriate state representatives and internal team(s) on member and provider appeals.
• Makes appropriate referrals to quality improvement, behavioral health, and complex case management. 
• Completes retrospective chart reviews and pended claims reviews as requested.
• Maintains strong collaborative working relationships with specialty, ancillary, and primary care providers.
• Documents completely and accurately within an electronic clinical record.
• Provides education on the utilization management process to members and providers as requested.
• Ensures utilization management program compliance and successful reimbursements by understanding applicable contract terms.
• Participates in care management as a member of an interdisciplinary team.
• Maintains knowledge of pertinent regulatory and accrediting requirements.
• Maintains HIPAA standards and compliance with all state and federal regulations. Ensures confidentiality of protected health information.
• Performs special projects as assigned.

Qualifications

• Licensed Registered Nurse (RN) in the state of residence is required, with the ability to obtain additional state licensure as needed
• 3+ years clinical nursing experience or the knowledge, skills, and abilities to succeed in the role
• Strong verbal and written communication skills
• Strong Ability to use good judgment
• Strong Effective organizational and customer service skills
• Working knowledge of contract terms as it relates to utilization management program compliance and reimbursement
• Working knowledge of HIPAA regulations and NCQA standards
• Ability to work effectively within a team
• Firm computer skills including Microsoft Office  
• Ability to multi-task and prioritize work

Preferred

• 2+ years of utilization review, discharge planning, or managed care
• Working knowledge of Medicare guidelines  
• Knowledge and use of InterQual Criteria  

Working Conditions

• While performing the duties of this job, the employee works in normal office working conditions.

#LI-Remote

Pay Transparency:

Factors that may be used to determine your actual pay rate include your specific skills, experience, qualifications, location, and comparison to other employees already in this role. In addition to the base salary, certain roles may qualify for a performance-based incentive and/or equity, with eligibility depending on the position. These rewards are based on a combination of company performance and individual achievements.

The hiring range for this position is:

$72,800.00-$97,400.00

Benefits of working at Lumeris

• Medical, Vision and Dental Plans

• Tax-Advantage Savings Accounts (FSA & HSA)

• Life Insurance and Disability Insurance

• Paid Time Off (PTO, Sick Time, Paid Leave, Volunteer & Wellness Days)

• Employee Assistance Program

• 401k with company match

• Employee Resource Groups

• Employee Discount Program

• Learning and Development Opportunities

• And much more...

Be part of a team that is changing healthcare!

Member Facing Position: No- Not Member or Patient Facing Position

Location:Remote, USA

Time Type:Full time

Lumeris and its partners are committed to protecting our high-risk members & prospects when conducting business in-person. All personnel who interact with at-risk members or prospects are required to have completed, at a minimum, the initial series of an approved COVID-19 vaccine. If this role has been identified as member-facing, proof of vaccination will be required as a condition of employment.Disclaimer:

• The job description describes the general nature and level of work being performed by people assigned to this job and is not intended to be an exhaustive list of all responsibilities, duties and skills required. The physical activities, demands and working conditions represent those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individual with disabilities to perform the essential job duties and responsibilities.

Lumeris is an EEO/AA employer M/F/V/D.