Utilization Management - Case Manager II (RN)

Socket.dev; Sarasota (FL); Hybrid; USD 70,000 - 100,000; Full time

Benefits offered by this job

PTO from day one

Tuition Reimbursement

Free Parking

Wellness Programs

Advancement opportunities

Job summary

Sarasota Memorial Health Care System is seeking a Utilization Management Case Manager (UMCM) to apply nursing expertise and critical thinking to determine appropriate care levels.

The UMCM will use evidence-based criteria, coordinate with ICM and Revenue Cycle, and collaborate with physicians to overturn denials when appropriate. The role also involves mentoring new staff and working across hospital teams to optimize payer approvals, while supporting organizational goals.

Qualifications

• BSN from an accredited school of nursing.
• Three years of utilization review experience.
• Minimum three years in an acute care setting.
• Experience with hospital information systems (order entry, results reporting, case management).
• Basic PC/computer skills.

Responsibilities

• Assess patients for clinically appropriate level of care.
• Collaborate with staff and payers to optimize utilization and approvals.
• Mentor and precept new staff within Integrated Case Management.

Skills

BSN

Utilization review

Acute care

Hospital IT systems

PC skills

Education

Bachelor of Science in Nursing (BSN)

Tools

Order entry systems

Results reporting

Case management systems

Job description

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.

Required Qualifications

• Require a Bachelor of Science in Nursing (BSN) from an accredited school of nursing.
• Require three (3) years of utilization review experience.
• Require a minimum of three (3) years in an acute care setting.
• Require previous experience with hospital information systems (order entry, results reporting, case management).
• Require basic experience using PC/computer (word processing minimum).

Preferred Qualifications

• Prefer active Case Management Certification (CCM or ACM) or within one (1) year of hire and membership in relevant CM/UM organization.
• Prefer demonstrated ability to manage multiple tasks and adjust priorities according to patient and department/hospital needs.
• Prefer solid clinical assessment, critical thinking, decision making and organizational skills.
• Prefer strong ability to communicate effectively both verbally and in written work.
• Prefer strong interpersonal skills and ability to work collaboratively with leaders, staff, patients, families, healthcare team, payers and external agencies.
• Prefer knowledge of relevant federal and state utilization review and appeal requirements.

Required License and Certs

FL RN: FL Registered Nurse License

*Hybrid role.

The Benefits of High-Quality Care:

• Paid Time Off (PTO) Start earning PTO on day one of employment
• Tuition Reimbursement
• Discounted medical, prescription, dental, vision plans both full and part time
• Flexible Spending Accounts (pre-tax dollars)
• Life Insurance
• Disability Insurance for those who quality (both short and long term)
• Retirement savings Plan: 403b
• Discounted Child care & Before and After school Program and Summer Camp! (Sarasota Campus)
• Free Parking
• On Campus discounted dining
• Free Wellness Screening
• Wellness Programs
• Referral Programs
• Advancement and growth opportunities for those hard-working and high performers!
• Work side by side with our amazing team players!

Employment Screening Requirements

As part of Sarasota Memorial Health Care System’s commitment to keeping people safe, all individuals providing care to vulnerable populations are required to undergo background screening through The Florida Care Provider Background Screening Clearinghouse. https://info.flclearinghouse.com/