Utilization Management - Case Manager II (RN)
About The Position
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, federal and 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.
Requirements
- Bachelor of Science in Nursing (BSN) from an accredited school of nursing.
- Three (3) years of utilization review experience.
- A minimum of three (3) years in an acute care setting.
- Previous experience with hospital information systems (order entry, results reporting, case management).
- Basic experience using PC/computer (word processing minimum).
- FL Registered Nurse License
Nice To Haves
- Active Case Management Certification (CCM or ACM) or within one (1) year of hire and membership in relevant CM/UM organization.
- Demonstrated ability to manage multiple tasks and adjust priorities according to patient and department/hospital needs.
- Solid clinical assessment, critical thinking, decision making and organizational skills.
- Strong ability to communicate effectively both verbally and in written work.
- Strong interpersonal skills and ability to work collaboratively with leaders, staff, patients, families, healthcare team, payers and external agencies.
- Knowledge of relevant federal and state utilization review and appeal requirements.
Responsibilities
- Assess patients for a clinically appropriate level of care.
- Maintain a strong knowledge base of evidence-based clinical criteria, federal and state UR requirements.
- Identify pertinent clinical information to support admission and continued stay hospitalization.
- Collaborate with floor ICM staff, Revenue Cycle, physicians, and Physician Advisors to overturn denials or determine appropriate patient transitions.
- Interact extensively with clinical staff, other ICM staff, physicians, payers, and hospital financial staff to achieve appropriate level of care or placement authorizations and avoid denials.
- Collaborate with other ICM staff to evaluate opportunities to optimize utilization and secure payer approvals across populations of patients.
- Act as a mentor/preceptor for new staff.
Benefits
- Paid Time Off (PTO) Start earning PTO on day one of employment
- Tuition Reimbursement
- Discounted medical, prescription, dental, vision plans both full and part time
- Flexible Spending Accounts (pre-tax dollars)
- Life Insurance
- Disability Insurance for those who quality (both short and long term)
- Retirement savings Plan: 403b
- Discounted Child care & Before and After school Program and Summer Camp! (Sarasota Campus)
- Free Parking
- On Campus discounted dining
- Free Wellness Screening
- Wellness Programs
- Referral Programs
- Advancement and growth opportunities for those hard-working and high performers!
- Work side by side with our amazing team players!
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
