Utilization Mgmt Case Mgr II
- Sarasota Memorial Hospital
- Sarasota, FL, USA
Job Description
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.
Mandatory Education
Preferred Education
Required License and Certs
FL RN: FL Registered Nurse License
Preferred License and Certs
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/
One of the largest public health systems in Florida, Sarasota Memorial Health Care System has continually evolved from its modest beginning as the county's first community hospital. Our mission to deliver high-quality healthcare for our community has been steadfast since we first began serving patients in 1925 at the 32-bed Sarasota Hospital, and our growth has been shaped by and for the Sarasota community.
Today, we are a full-service public health system, with two hospitals offering specialized expertise in heart, vascular, cancer, orthopedic and neuroscience services, as well as a state-of-the-art cancer care center and a network of outpatient centers, urgent care centers, laboratories, diagnostic imaging and physician practices, skilled nursing and rehabilitation among our many programs. Sarasota Memorial also serves as the region's health care safety net, with Sarasota County's only trauma center, obstetrical services, neonatal intensive care unit, inpatient pediatrics unit and psychiatric services for patients of all ages.
The system's flagship 897-bed campus, Sarasota Memorial Hospital-Sarasota, has been consistently recognized as one of the nation’s best hospitals. A regional referral center providing the greatest depth and breadth of care to the community, the campus also includes state-of-the-art specialized centers of care, including the Brian D. Jellison Cancer Institute Oncology Tower, Rehabilitation Pavilion and newly opened Cornell Behavioral Health Pavilion.
With the opening of Sarasota Memorial Hospital-Venice in fall 2021, we're able to provide south Sarasota County residents convenient access to the same level of care and 5-Star physicians, staff and systems available at our SMH-Sarasota Campus. SMH-Venice features 178 private rooms, a 28-room Emergency Care Center, 8 surgical suites, 10 birthing suites and a pandemic-ready intensive care unit. The Venice campus is currently undergoing an expansion that will double the hospital's capacity when complete in 2024.
Sarasota Memorial is powered by more than 10,000 staff and is Sarasota County’s largest employer. Over 700 members of the community contribute their time and skills as hospital volunteers; this includes the 9-member Sarasota County Public Hospital Board elected by local voters, governs Sarasota Memorial Health Care System.
Our Mission
Sarasota Memorial strives to provide healthcare services that excel in caring, quality and innovation.
Our Vision
Our community will be served by the best healthcare system in the nation. Sarasota Memorial will be the best place to be a patient, the best place to work and the best place to practice medicine. Our extraordinary people, innovative clinical technology and effective use of information systems will set us apart. We will deliver services that are safe, result in desired outcomes and are consistent with current professional knowledge.
Our Values
To create an environment that supports and rewards:
- Safety
- Caring and compassion
- Excellence and professionalism
- Teamwork and trust
- Mutual respect and recognition
- Accountable and ethical behavior