Pool Case Manager Utilization Review

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

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