Utilization Mgmt Case Mgr III

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.

- Require a Bachelor of Science in Nursing (BSN) from an accredited school of nursing.
- Require five (5) years of case management or utilization review experience in a hospital setting; utilization experience preferred. - Require a minimum of three (3) years of related clinical practice in an acute care setting.
- Require active Case Management Certification (CCM or ACM-RN) and membership in relevant CM/UM organization.
- Require previous experience with hospital information systems (order entry, results reporting, case management). - Require basic experience using PC/computer (word processing minimum).

- Prefer solid clinical assessment, critical thinking, decision making and organizational skills.
- Prefer strong ability to communicate effectively both verbally and in written work.
- Prefer knowledge of relevant federal and state utilization review and appeal requirements.
- Prefer strong interpersonal skills and ability to work collaboratively with leaders, staff, patients, families, healthcare team, payers and external agencies.
- Prefer demonstrated ability to manage multiple tasks and adjust priorities according to patient and department/hospital needs.

FL RN: FL Registered Nurse License