UM Case Manager - Utilization Management

Responsibilities:

1. Coordinates/facilitates patient care progression throughout the continuum of care.

2. Assures the plan of care and services provided are patient focused, high quality, efficient, and cost effective.

3. Communicates with payer the medical necessity for the status and LOC ordered to obtain authorization and reimbursement for care rendered.

4. Monitors length of stay and ancillary resource use on an ongoing basis and takes actions to achieve continuous improvement in both areas.

5. Communicates information to the Case Management team to aid in appropriate level of care determination and reimbursement by third party payors.

6. Communicates identified issues affecting quality of care, risk management, patient satisfaction and or physician opportunities to the quality team using the Improve the Process form.

7. Ensures that all payer communication is documented for the care team as well as billing.

8. Ability to cover various populations across the organization in relation to Utilization Review.

9. Performs all other duties as requested by Case Manager Supervisor and/or Director. 

Qualifications:

• 1-2 years of recent acute care hospital experience required

• Data entry/computer experience required. 

Requirements:
  Licenses and Certifications:
    Registered Nurse