Case Manager, RN- Utilization Review

Tampa General Hospital•Tampa, FL

13h•Onsite

About The Position

The Utilization Review Case Manager validates the patient's placement to be at the most appropriate level of care based on nationally accepted admission criteria. Team member uses medical necessity screening tools, to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient's expected length of stay. The Utilization Review Case Manager secures authorization for the patient's clinical services through timely collaboration and communication with payers as required. The Utilization Review Case Manager follows the process as defined in the Utilization Review Plan in accordance with the TGH Conditions of Participation for Utilization Review.

Requirements

Associate’s Degree Nursing
Registered Nurse
Three (3) years as a practicing RN in an acute care setting
at least two (2) years’ experience as a case manager
HMO/Managed Care/Medicare/Medicaid experience

Responsibilities

Admissions Reviews
Concurrent Reviews
Case Escalations for appropriate status
Concurrent Denials Management
Interdisciplinary discussions and Provider partnerships
Monitor and manage all inpatient hospital admissions with the goal of achieving cost- effective patient care.
Identifies when those situations where criteria is not met for admission and discuss issues with the attending physician
Utilize clinical skills, chart review, physician communication and clinical screening tool and utilize peer review as necessary.
Identify when those situations where criteria is not met for admission and discuss issues with the attending physician, refer all appropriate cases to the ACMO or Physician Advisory Service.
Follow established policies, procedures and professional guidelines while working closely with Resource Center Associates, Care Coordinators, Nursing and Providers to obtain clinical information to justify proposed services and care; establish strong relationships with Managed Care Organizations to enhance the ability to obtain authorizations for services
Liaises with the manager and reports all situations requiring management intervention
Will perform job functions in accordance with mission, vision and values of Tampa General Hospital.