Job Description

This position may qualify for a sign-on bonus

The individual in this position is responsible to facilitate 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. This position integrates national standards

for case management scope of services including:

• Utilization Management services supporting medical necessity and denial prevention
• Coordination with payers to authorize appropriate level of care and length of stay for medically necessary

services required for the patient

• Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
• Education provided to payers, physicians, hospital/office staff and ancillary departments related to covered

services and administration of benefits

The individual’s responsibilities include the following activities: a) accurate medical necessity screening and

submission for Physician Advisor review, b) securing and documenting authorization for services from payers, c)

managing concurrent disputes, d) collaborating with payers, physicians, office staff and ancillary departments, e)

timely, complete and concise documentation in the Tenet Case Management documentation system, f)

maintenance of accurate patient demographic and insurance information, g) identification and documentation of

potentially avoidable days, h) identification and reporting over and underutilization, i) and other duties as

assigned

MINIMUM EDUCATION: Graduate of an accredited School of Nursing

PREFERRED EDUCATION: Associates in Nursing

MINIMUM EXPERIENCE: 2 years acute hospital or behavioral health patient care experience with at least

1 year utilization review in an acute hospital or commercial/managed care payer setting.

PREFERRED EXPERIENCE: 1 year hospital acute or behavioral health case management experience.

REQUIRED CERTIFICATIONS/LICENSURE: Must be currently licensed, certified or registered to practice

profession as required by law or regulation in state of practice or policy. Active LVN/LPN license for

state(s) covered.

PREFERRED CERTIFICATIONS/LICENSURE: Accredited Case Management (ACM)

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Baptist Health System Hospital is committed to providing exceptional patient care in a supportive and collaborative environment. As a member of our team, you will have the opportunity to work with advanced technology and be part of a healthcare community dedicated to making a positive impact on the lives of our patients.

At Baptist Health System, we understand that our greatest asset is our dedicated team of professionals. That’s why we offer more than a job – we provide a comprehensive benefit package that prioritizes your health, professional development, and work-life balance. The available plans and programs include:

• Medical, dental, vision, and life insurance
• 401(k) retirement savings plan with employer match
• Generous paid time off
• Career development and continuing education opportunities
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance

Note: Eligibility for benefits may vary by location and is determined by employment status