Pool Case Manager Utilization Review

Tampa General Hospital; Town of Florida, Northern (NY, KY); Hybrid; USD 85,000 - 110,000; Full time

Job summary

Tampa General Hospital is seeking a Pool Case Manager Utilization Review to validate patient placement and ensure the most appropriate level of care. The role uses screening tools to complete initial and continued stay reviews and secures authorization through payers.

Collaboration with providers and payers is essential within the Utilization Review Plan. Required is an RN license and at least 3 years of acute care nursing plus 2 years in case management, with experience in Medicare/Medicaid and

Qualifications

• Associate's Degree in Nursing required.
• Registered Nurse license issued by Florida or a compact state.
• Minimum 3 years as an RN in an acute care setting.
• Minimum 2 years in case management.
• Experience with HMO/Managed Care/Medicare/Medicaid.

Responsibilities

• Admissions Reviews
• Concurrent Reviews
• Case Escalations for appropriate status
• Concurrent Denials Management
• Interdisciplinary discussions and provider partnerships

Skills

RN

Case management

Payer coordination

Education

Associate's Degree in Nursing

Job description

Job Description

Job Number:

Pool Case Manager Utilization Review (260003NE )

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. 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.

Essential Functions

• 1. Admissions Reviews
• 2. Concurrent Reviews
• 3. Case Escalations for appropriate status
• 4. Concurrent Denials Management
• 5. Interdisciplinary discussions and Provider partnerships

Qualifications

Education

• Associate's Degree- Nursing

License/Registration

• Registered Nurse- Issued by Florida or Compact State

Work Experience and Additional Information

• Three (3) years as a practicing RN in an acute care setting and
• least two (2) years’ experience as a case manager

HMO/Managed Care/Medicare/Medicaid experience