CASE MGR, UTILIZATION REVIEW – Broward Health Corporate – Fort Lauderdale, FL

The individual in this position is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity and to assess the patient for transition needs to promote timely throughput, safe discharge and prevent avoidable readmissions. This position integrates national standards for case management scope of services including:

• Utilization Management supporting medical necessity and denial prevention
• Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
• Communication with the Care Coordination team by demonstrating efficient throughput while assuring care is sequenced and at appropriate level of care
• Compliance with state and federal regulatory requirements, TJC accreditation standards and policy
• Education provided to physicians, patients, families and caregivers

The individual’s responsibilities include the following activities: a) accurate medical necessity screening and submission for Physician Advisor review, managing concurrent disputes, making appropriate referrals to other departments, collaborating with physicians, office staff and ancillary departments, leading and facilitating Complex Case Review, timely complete and concise documentation in the Case Management documentation system, maintenance of accurate patient demographic and insurance information, identification and documentation of potentially avoidable days, identification and reporting over and underutilization, and other duties as assigned.