Case Manager, RN- Utilization Review

Tampa General Hospital; Tampa, Northern (FL, KY); On-site; USD 75,000 - 105,000; Full time

Job summary

Tampa General Hospital in Tampa, FL seeks an experienced Utilization Review Case Manager to validate patient placement and drive appropriate levels of care using national criteria.

You will perform admissions and concurrent reviews, manage denials, and collaborate with physicians and care teams to obtain timely authorizations and ensure high-quality, cost-effective patient care.

Qualifications

• Associate’s Degree Nursing required.
• Registered Nurse license.
• Three years' RN in acute care, plus two years' case management experience.
• Experience with HMOs/Managed Care/Medicare/Medicaid.

Responsibilities

• Perform admissions reviews to determine level of care.
• Conduct concurrent reviews and monitor patient status.
• Manage concurrent denials and coordinate with providers.
• Engage in interdisciplinary discussions and partnerships with care teams.
• Adhere to Tampa General Hospital policies and guidelines while securing authorizations.

Skills

Admissions Reviews

Concurrent Reviews

Denials Management

Provider Partnerships

Clinical Skills

Physician Communication

Peer Review

Policy Compliance

Education

Associate’s Degree Nursing

Job description

Job Description

Description

A Brief Overview

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. 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

Education Qualifications

• Associate’s Degree Nursing

Licenses and Certifications

• Registered Nurse

Experience Qualifications

• Three (3) years as a practicing RN in an acute care setting and least two (2) years’ experience as a case managerHMO/Managed Care/Medicare/Medicaid experience

Skills and Abilities

• Monitor and manage all inpatient hospital admissions with the goal of achieving cost- effective patient care.
• Identifies when those 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 tool and utilize peer review as necessary.
• Identify when those situations where criteria is not met for admission and discuss issues with the attending physician, 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
• Liaises with the manager and reports all situations requiring management intervention
• Will perform job functions in accordance with mission, vision and values of Tampa General Hospital.

Primary Location

Tampa

Work Locations

TGH Main Campus 1 Tampa General Circle Tampa 33601

Remote Work Eligibility

Fully Remote

Job

Case Management

Schedule

Full-time

Scheduled Days

Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday