Provides guidance and acts as a liaison for the team of Operations and Care Managers team, as well as customers both intra-department and inter-departmentally.
Identifies high-risk members, monitors, assesses, and evaluates health care needs, collaborates and coordinates care and services between healthcare providers and care managers.
Organizes, distributes and communicates daily census reports, tracking and trending reports, and identifies gaps in transitions of care.
Adheres to case management standards of practice for care management promoting quality care and cost-effective outcomes that enhance physical, psychosocial and vocational health of individuals.
Performs and provides oversight for activities involved in the Operations and Utilization Management team including clinical reviews, appeals reviews, Care Management activities, and quality assurance activities.
Assists leadership team in meeting and reporting department goals and key quality indicators (KQI). Supports quality initiatives.
Meets or exceeds performance measures and service standards such as turnaround times, transition of care, quality measures, avoidable readmits, and length of stay.
Meets with Care Management leadership team as scheduled.
Performs other duties as assigned or directed to ensure the smooth operation of the department
Participates in committees, teams or other work projects/duties as assigned.
What You Will Need:
Education and Experience Required:
Graduate of a school of nursing – minimum Associates Nursing Program
Experience in clinical nursing with a minimum of three years’ experience
3-5 years’ experience in any one of the following areas: utilization management, insurance/managed care industry, case management
Knowledge and Skills Required:
Comprehensive knowledge and understanding of chronic and acute disease conditions, management, and treatment
Comprehensive knowledge and understanding of utilization management criteria (ie: Interqual, Milliman)
Ability to interact effectively with physicians and other health care professionals
Excellent written and verbal communication skills in English
Computer and typing skills, including Excel and Microsoft office, specifically spreadsheets and report building
Licensure, Certification or Registration Required:
Current Active State of Florida license as a Registered Professional Nurse
Certified Case Manager (CCM) Preferred
The function of the Utilization Management Care Manager is to coordinate care, educate members and providers, and provide interventions within the scope of case management practice that have direct influence on clinical and financial outcomes. Responsibilities includes identification of high-risk patients, assessment of healthcare needs, collaboration and coordination with health care providers, quality management activities, process review and development, clinical reviews and reports to distribute care across teams, and coordination and support of inpatient and outpatient utilization management activities. Participates in the process to identify and facilitate options and services for meeting individuals' health care needs, while decreasing fragmentation and duplication of care and enhancing quality and cost-effective clinical outcomes. Shared accountability for cost savings and meeting department utilization metric goals. Responsible for ensuring efficient care management outcome measures and compliance with regulatory requirements. Attends pertinent seminars, workshops and professional meetings to maintain up-to-date knowledge base as it relates to the Care Management. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.