Job Description

Fulltime: Monday - Friday

The Case Manager – Utilization Review is responsible for evaluating the medical necessity, appropriateness, and efficiency of healthcare services provided to patients. This role ensures compliance with regulatory requirements, payer guidelines, and hospital policies while promoting optimal patient outcomes and effective resource utilization. The Case Manager collaborates with physicians, nursing staff, and payers to support timely care progression, appropriate level of care determinations, and safe discharge planning.

Pre-Employment Requirements:

• We are a drug free facility. Passing a pre-employment drug screening is required.

EDUCATION REQUIREMENTS

• Graduate of an accredited school of nursing required (LPN or RN).
• Additional education in case management, healthcare administration, or a related field preferred.

LICENSURE/CERTIFICATIONS:

• Registered Nurse (RN) license in the State of Alabama required, or a current multistate license in a Nurse Licensure Compact (NLC) state permitting practice in Alabama.
• Certification in Case Management (e.g., CCM) or Utilization Review preferred.

EXPERIENCE/QUALIFICATIONS:

• Minimum of one (1) year of clinical experience required.
• Experience working as a clinical nurse in an acute care or comparable healthcare setting required.
• Prior experience in case management, utilization review, or discharge planning preferred.
• Experience with payer guidelines, medical necessity criteria (e.g., InterQual, MCG), and insurance authorization processes preferred.
• Demonstrates the ability to carry out detailed written or verbal instructions independently.
• Strong clinical assessment and critical thinking skills.
• Knowledge of utilization review criteria (e.g., InterQual, MCG) and payer requirements.
• Excellent communication and negotiation skills when working with providers and insurers.
• Ability to analyze clinical data and make appropriate level-of-care determinations.
• Strong organizational skills with the ability to manage multiple cases simultaneously.
• Proficiency in electronic medical records (EMR) and documentation systems.
• Understanding of regulatory and accreditation standards (CMS, Joint Commission).