Utilization Mgmt Case Mgr II

About the role

The Utilization Management Case Manager (UMCM) is responsible for assessing patients for a clinically appropriate level of care, maintaining a strong knowledge base of clinical criteria, and collaborating with various stakeholders to overturn denials or facilitate appropriate transitions.

Responsibilities

• Assess patients for clinically appropriate levels of care
• Maintain knowledge of evidence-based clinical criteria, UR requirements, and pertinent clinical information
• Collaborate with floor ICM staff, Revenue Cycle, involved physicians, and PA as needed to obtain second-level review/approval
• Evaluate opportunities to optimize utilization and secure payer approvals across patient populations
• Interact extensively with clinical staff, other ICM staff, physicians, payers, and hospital financial staff
• Avoid denials and assist in determining appropriate patient placements
• Act as a mentor/preceptor for new staff members

Requirements

• Bachelor of Science in Nursing (BSN) from an accredited school of nursing
• Three (3) years of utilization review experience, including at least three (3) years in an acute care setting
• Basic experience using PC/computer (word processing minimum)

Preferred Qualifications

• Active Case Management Certification (CCM or ACM) or within one (1) year of hire
• Membership in relevant CM/UM organization
• Demonstrated ability to manage multiple tasks and adjust priorities
• Solid clinical assessment, critical thinking, decision-making, and organizational skills
• Strong communication abilities, both verbal and written
• Strong interpersonal skills and collaborative abilities
• Knowledge of relevant federal and state utilization review and appeal requirements