Utilization Mgmt Case Mgr I

Department

Integrated Case Management

Job Summary

The Utilization Management Case Manager (UMCM) utilizes professional nursing and critical thinking skills to assess patients for a clinically appropriate level of care. The UMCM maintains a strong knowledge base of evidence based clinical criteria (Milliman), and federal, state UR requirements, and adeptly identifies pertinent clinical information that will support admission and continued stay hospitalization. When potential denials for payment or level of care arise, the UMCM collaborates with the floor ICM staff, Revenue Cycle, involved physicians and / or the Physician Advisors (PA) as needed to attain second level review / approval to effectively overturn the denial or help determine appropriate transition for the patient. UMCM interact extensively with clinical staff throughout the hospital, other ICM staff, physicians, payers, and hospital financial staff in order to achieve appropriate level of care or placement authorizations, and to avoid denials. The UMCM collaborates with other ICM staff to evaluate opportunities to optimize utilization and secure payer approvals across populations of patients to meet organizational strategic objectives. The UMCM acts as a mentor / preceptor for new staff.

Required Qualifications

• Require one (1) year of case management or utilization review experience in a hospital setting; utilization experience preferred or qualified graduate of the SMHCS internal ICM Residency program.
• Require a minimum of three (3) years of related clinical practice in an acute care setting.
• Require Diploma / Associates degree in Nursing with graduation from an accredited school of nursing.
• Require basic experience using PC / computer (word processing minimum).
• Require previous experience with hospital information systems (order entry, results reporting, case management).

Preferred Qualifications

Mandatory Education

Preferred Education

BSN : Bachelor of Science Nursing

Required License and Certs

FL RN : FL Registered Nurse License

Preferred License and Certs