Utilization Review-Case Management (Full-Time)

As a Utilization Review-Case Manager, you are expected to conduct admission, concurrent, and extended stay reviews for both inpatient and outpatient services. This involves preparing and submitting payment appeals to third-party payers while maintaining accurate records. Your role also includes training staff and ensuring confidentiality and compliance with healthcare standards.

To qualify for the Utilization Review-Case Manager position, candidates should possess two or more years of experience in a managed care environment. A current license as RN, LVN/LPT, or LCSW is preferred, along with a Master’s degree in Social Work, Behavioral Science, or a related field. Familiarity with medical terminology and third-party reimbursement processes is essential.

The Utilization Review-Case Manager role features a structured work schedule from Monday to Friday, 8:00 a.m. to 4:30 p.m. This allows for a predictable routine while supporting a healthy work-life balance.

Successful Utilization Review-Case Managers exhibit strong organizational and communication skills, good judgment, and an ability to work independently as well as part of a team. Additionally, having a strong understanding of healthcare delivery systems and the ability to work under pressure is crucial.

Utilization Review-Case Managers can look forward to a competitive benefits package that includes health, dental, and vision insurance, a 401K Retirement Plan, PTO, short and long-term disability, tuition reimbursement, and more, ensuring overall well-being and career development opportunities.

When answering this question, detail your past roles where you performed admission reviews, highlighting specific cases or examples to illustrate your method and approach to ensuring patient care aligns with the standards.

Consider sharing a specific time where you successfully managed stress. Discuss techniques you use such as prioritization, time management strategies, and perhaps how you take breaks to ensure productivity remains high.

Demonstrate your understanding of the terms used in healthcare. Discuss specific examples of how you've applied this knowledge in previous roles, such as understanding diagnoses, treatments, and patient records.

Detail your structured approach to the appeals process, including how you gather data, collaborate with healthcare providers, and ensure that each appeal is comprehensive and well-supported.

Share a specific training session or initiative, what topics were covered, and the positive outcomes that resulted from your training efforts, focusing on how you tailored the session to meet the needs of diverse team members.

Discuss the importance of confidentiality in the healthcare field and the specific protocols or practices you follow to safeguard patient information, including HIPAA compliance and secure record-keeping.

Highlight your communication skills, collaboration methods, and specific experiences where you’ve worked with professionals from different fields to create a well-rounded approach to patient care.

Reflect on a particularly challenging situation, explaining what happened, how you responded, and the positive resolution that followed, showcasing your adaptability and problem-solving abilities.

Discuss your thought process for prioritizing, including factors such as deadlines, patient impact, and collaboration with other team members, demonstrating your systematic approach to workload management.

Share your motivations for the role, connecting your passion for patient care with the impact that accurate utilization review has on healthcare outcomes, and how you believe your skills align with the goals of the position.