Archived listing. The details below describe a past opening.
The Case Manager II - Utilization Review coordinates care and services for patient populations throughout the acute care episode and across the continuum of care. This role works collaboratively with interdisciplinary teams, both internal and external to the organization, to improve patient outcomes through effective utilization management, authorization oversight, resource stewardship, and transition planning.
Key Responsibilities
Utilization Management & Authorization
- Perform admission and concurrent reviews for medical necessity, appropriate level of care, and admission status using McKesson InterQual and MCG criteria.
- Maintain communication with third-party payers to secure inpatient authorizations and continued stay approvals.
- Submit clinical documentation required to support authorization and reimbursement.
- Monitor hospital resource utilization and ensure compliance with payer requirements.
Denials Management & Appeals
- Manage concurrent inpatient denials, including second-level reviews, reconsiderations, peer-to-peer coordination, and real-time appeals.
- Escalate complex authorization and medical necessity concerns to physician advisors, medical directors, and leadership.
- Support efforts to minimize denials and maximize reimbursement.
- Follow and appeal post-discharge denials as required.
Care Coordination & Transition Planning
- Assess, plan, communicate, educate, and coordinate transition planning activities for patients and families.
- Document utilization review activities, authorization determinations, denials, appeals, and discharge planning efforts within the medical record.
- Collaborate with interdisciplinary teams to ensure continuity of care and successful patient outcomes.
Leadership & Performance Improvement
- Identify authorization barriers and opportunities to improve payer compliance.
- Support length-of-stay management and throughput initiatives.
- Participate in auditing activities, data analysis, provider education, payer update distribution, software rollouts, and revenue cycle support activities.
- Serve as a resource for utilization review best practices and reimbursement optimization.
Minimum Qualifications
Education
- Graduate of an RN or LPN Diploma/Certificate Program, or
- Associate's Degree in Nursing, or
- Bachelor's Degree in Nursing.
Licensure
- Current Registered Nurse (RN) or Licensed Practical Nurse (LPN) license in the State of Georgia.
Experience
- Five (5) years of acute care clinical experience preferred.
Preferred Knowledge, Skills & Abilities
- Utilization review and case management experience
- Knowledge of healthcare reimbursement and funding sources
- Understanding of healthcare delivery and financing systems
- Strong clinical assessment and critical thinking skills
- Excellent written and verbal communication skills
- Problem-solving and organizational abilities
- Ability to work independently in a remote environment
- Experience collaborating with interdisciplinary healthcare teams
- Familiarity with medical necessity criteria and payer authorization processes