RN-Case Management Analyst
Company: Tailored Management
Posted on: November 22, 2021
Case Management Analyst
Location: Nashville, TN
Hours: M-F 8-4:30
Responsible for collaborating with healthcare providers and members
to optimize member benefits and to promote effective use of
Assesses the medical necessity of inpatient admissions, outpatient
services, surgical and diagnostic procedures, and out of network
May also manage appeals for services denied.
May conduct pre-certification, concurrent and retrospective reviews
to ensure compliance with medical policy, member eligibility,
benefits, and contracts.
May be responsible for day-to-day operations of a single or
multiple IPA/IPOD and staff, and may serve as liaison with the
local health plan to ensure continuity for IPA/IPOD members.
Essential Duties and Responsibilities:
-Responsible for the effective and sufficient support of all
Utilization Management activities to include
prospective/pre-certification review of inpatient and outpatient
medical services for medical necessity and appropriateness of
setting according to established policies.
-Evaluates and authorizes the medical necessity of some inpatient
and outpatient services.
-Notifies provider of recommended changes in level of care.
-Evaluates cases for quality of care and documents quality
Issues letter to provider and member if the service meets
certification criteria, and escalates to manager or Medical
Director for review if the service does not meet certification
criteria, and may issue denial letters.
Knowledge, Skills, Abilities Required:
-Excellent interpersonal and communications skills with clinical
staff, management, and all departments involved in the care of our
-Ability to meet deadlines, make decisions on what needs to be done
and manage multiple priorities, and effectively adapt and respond
to complex, fast-paced team environment and to promote team
Current license as an RN in the state of Tennessee Required.
At least one year clinical, utilization management and/or case
Working knowledge of the insurance industry and the overall claims
process a plus.
Keywords: Tailored Management, Nashville , RN-Case Management Analyst, Executive , Nashville, Tennessee
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