Case Manager, RN- Utilization Review

A Brief Overview

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.

What You Will Do

• Admissions Reviews
• Concurrent Reviews
• Case Escalations for appropriate status
• Concurrent Denials Management
• Interdisciplinary discussions and Provider partnerships

• Education Qualifications
• Associate’s Degree Nursing
• Licenses and Certifications
• Registered Nurse

Experience Qualifications

Three (3) years as a practicing RN in an acute care setting and least two (2) years’ experience as a case managerHMO/Managed Care/Medicare/Medicaid experience

Skills and Abilities

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.