Case Manager, RN- Utilization Review

Under the general supervision of the Utilization Management Manager and in accordance with established policies, professional guidelines, and CMS Conditions of Participation for Utilization Review, the Utilization Management Nurse (UMN) ensures patients are assigned to the most appropriate level of care based on nationally recognized admission and continued stay criteria. The UMN performs admission, concurrent, and retrospective utilization reviews using clinical expertise and medical necessity screening tools; evaluates appropriateness of services and expected length of stay; and supports timely authorization determinations through collaboration with payers. The UMN works closely with physicians, Care Coordinators, Resource Center Associates, Nursing, and leadership to address cases where criteria are not met, escalate concerns to the Physician Advisor or appropriate medical leadership, participate in denial management, and support efficient patient flow. All duties are performed in alignment with Tampa General Hospital’s mission, vision, values, and quality standards. 

Technical Knowledge, Skills, and Abilities

• In‑depth knowledge of utilization review processes, nationally recognized medical necessity criteria (e.g., InterQual or similar), and appropriate level‑of‑care determination.

• Ability to apply clinical nursing knowledge to evaluate the appropriateness of admissions, continued stays, diagnostic testing, and treatment plans.

• Knowledge of Medicare, Medicaid, managed care, and commercial payer requirements, including authorization, denial, and appeal processes.

• Ability to identify cases where criteria are not met, analyze complex clinical and payer‑specific issues, and escalate appropriately through physician, Physician Advisor, and leadership channels.

• Strong communication skills with the ability to effectively collaborate with physicians, payers, interdisciplinary teams, and leadership to justify medical necessity, resolve denials, and support patient flow.

• Proficiency in accurate, timely documentation of utilization reviews, payer communications, and determinations using electronic medical records and utilization management systems.

   

Essential Functions

• Conducts initial admission reviews using nationally accepted criteria to determine medical necessity, appropriate level of care, and patient status designation.

• Performs concurrent and ongoing reviews to assess continued stay, appropriateness of services, and expected length of stay, ensuring alignment with clinical presentation and regulatory requirements.

• Reviews retrospective cases and participates in denial management, including preparation of clinical documentation and support for appeals in collaboration with Physician Advisors and Appeals teams, when appropriate.

• Collaborates with payers regarding medical necessity determinations, authorization decisions, and continued stay reviews for inpatient admissions and clinical services.

• Identifies cases where admission or continued stay criteria are not met and communicates findings with the attending physician, escalating to the Physician Advisor or appropriate medical leadership as needed.

• Works closely with Care Coordinators, Resource Center Associates, Nursing, Physicians, and leadership to support appropriate patient status, care progression, and effective utilization of hospital resources.

• Promotes appropriate status designation and medical necessity decisions to support timely patient movement and efficient hospital throughput.

• Documents all utilization reviews, payer intera