Utilization Management Case Manager

About This Role

Manage utilization, quality assurance, and discharge planning activities for assigned patients within Cottage Health. This role ensures quality outcomes, optimal care, cost management, and high customer satisfaction.

Responsibilities

• Understand reimbursement principles and services within reimbursement parameters.
• Ascertain healthcare benefits utilizing internal and external resources to coordinate necessary care.
• Identify and refer situations requiring immediate intervention to appropriate personnel.
• Refer cases not meeting criteria to the department director and/or physician advisor.
• Maintain accurate and thorough documentation of resource management activities.
• Initiate coordination and development of a discharge plan upon patient admission.
• Provide appropriate information, education, and choice for post-discharge needs.
• Facilitate the transfer of patients to other care facilities as appropriate.
• Participate in the improvement of organizational performance through quality assurance activities.
• Educate patients and families on the care delivery process, funding issues, and patient choice.

Requirements

• Excellent organizational and analytical skills
• Ability to make independent decisions and utilize effective problem-solving models
• Working knowledge of regulations and provider contracts governing coverage of inpatient services (e.g., Medicare, Medi-Cal)
• Ability to demonstrate an understanding of InterQual criteria
• Ability to assess discharge planning needs of a diverse population

Qualifications

• Associate's Degree in Nursing (ADN) or Bachelor's Degree in Nursing (BSN)