Case Manager Utilization Review

Job Summary The Utilization Review Case Manager validates the patient’s placement to be at the most appropriate level of care based on nationallyaccepted admission criteria. The UR Case Manager uses medical necessity screening tools, to complete initial and continued stay reviews indetermining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient’s expected length of stay.The UR Case Manager secures authorization for the patient’s clinical services through timely collaboration and communication with payersas required. The UR Case Manager follows the UR process as defined in the Utilization Review Plan in accordance with the CMS Conditionsof Participation for Utilization Review. Under general supervision of the Utilization Management Manager, the Utilization Management Nurse will 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 foradmission and discuss issues with the attending physician; Utilize clinical skills, chart review, physician communication and Interqual Levelof Care and utilize peer review as necessary. Identify when those situations where criteria is not met for admission and discuss issues with theattending physician, refer all appropriate cases to the ACMO or Physician Advisory Service. The UR Case Manager will follow establishedpolicies, procedures and professional guidelines while working closely with Resource Center Associates, Care Coordinators, Nursing andPhysicians to obtain clinical information to justify proposed services and care; establish strong relationships with Managed CareOrganizations to enhance the ability to obtain authorizations for services; liaises with the manager and reports all situations requiringmanagement intervention; UR Case Manager will perform job functions in accordance with mission, vision and values of Tampa General Hospital.The primary areas of responsibilities are: concurrent utilization review, retrospective and/or denials management and interactions withdepartment and staff of TGH to ensure good patient flow through appropriate status and medical necessity designations.

Duties

Admission Reviews

Concurrent Reviews

Case Escalations for appropriate status

Concurrent Denials Management Interdisciplinary discussions and physician partnerships

Qualifications

Graduate of an accredited school of nursing; Associates Degree Required, z

Florida state RN license

Three (3) years as a practicing RN

Atleast two (2) years’ experience in a health care setting

HMO/Managed Care/Medicare/Medicaid experience preferred.

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