[Hiring] Case Manager, RN - Utilization Review @Tampa General Hospital

Role Description

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. The 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

Qualifications

• Associate’s Degree in Nursing
• Registered Nurse License

Requirements

• 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

Skills and Abilities

• Monitor and manage all inpatient hospital admissions with the goal of achieving cost-effective patient care.
• Identify 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 tools; utilize peer review as necessary.
• 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.
• Liaise with the manager and report all situations requiring management intervention.
• Perform job functions in accordance with the mission, vision, and values of Tampa General Hospital.