Utilization Management - Case Manager II (RN)

Department

Integrated Case Management

Job Summary

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.