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Case Manager/Utilization Review Coordinator Position


Case Manager/Utilization Review Coordinator

Job Description:

The Case Manager (CM) is responsible for assessing, planning, facilitating, coordinating, evaluating and advocating for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.

The CM is responsible and accountable for the Case Management of all patients to facilitate efficient, cost-effective, quality care, including appropriate utilization of resources, proactive discharge planning, continuity of care, multidisciplinary team approach and patient advocacy.  The CM acts as the primary agent on the multidisciplinary care team to facilitate the patient’s movement through the continuum of care while ensuring the maximum outcome goals for the patient are achieved. 

·         Communicates and interacts directly with all members of the multidisciplinary care team, the patient and family/significant others for planning and facilitating the plan of care for each patient

·         Analyzes care needs of the patients, implements care plan with measurable goals and monitors progress toward achieving desired outcome goals; revises care plan as needs change

·         Tracks and analyzes clinical and financial data to support clinical decision-making.  In addition, the CM interacts with referral sites and community providers for coordinating appropriate patient care needs during each transition of care.

·         Reviews all admissions for medical necessity and reviews daily for the medical necessity for continued stay

·         Reviews the Utilization Review  (UR) Plan annually and revises as necessary to meet regulatory requirements

·         Coordinates the quarterly UR meetings and utilizes quality management tools to improve organizational performance relative to decreased costs, appropriate resource utilization and performance improvement

·         Reviews all case denials for non-payment and coordinates appeal responses; tracks and trends for UR and performance improvement opportunities.

·         Performs CM/UR department requirements in accordance with all Federal and State guidelines.



·         Current RN licensure in the State of KY; Bachelor’s Degree in nursing preferred. 

·         Minimum of three years’ experience in an acute adult patient care clinical role.

·         1-2 years Case Management experience in health care environment preferred.

·         Computer Knowledge:  Must have strong computer skills; proficient in Microsoft Office (Word, Outlook and Excel)

·         Working knowledge of criteria for Medicare, Medicaid, HMO and private insurance coverage.

·         Knowledge of InterQual criteria preferred

·         Exhibit critical thinking, problem-solving and analytical skills

·         Self-initiative with ability to lead and motivate others

·         Interpersonal communication skills (written and oral)

Language Skills:

·         Ability to read and communicate effectively in English.

·         Additional languages preferred.



Reports to:  Chief Nursing Officer                     

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