A utilization management case manager generally works for an insurance entity and analyzes individual medical cases to determine eligibility for medical care. The case manager will obtain pre-certification for patients and conduct reviews to determine if patients are eligible for inpatient or outpatient services or home care based on patient benefit and coverage rules. When patients are not covered for certain services, the case manager will review the cases and determine if the care is needed by analyzing medical records.
Problem-solving skills are necessary in order to analyze all relative information and make accurate, objective decisions. When cases indicate that this care is needed, the case manager must make recommendations to management. Much of the work is done independently and he/she will often work on many cases at once, so the ability to multitask is essential. Of course, these managers must also do all work according to company policy and the law, as well as meet all deadlines and provide decisions in a timely manner.
Many positions require applicants to have a Bachelor’s degree in a health-related field and be currently-licensed registered nurses with a few years of clinical experience. Strong computer skills are needed in order to keep track of records, documents, and programs which may be used to carry out work.
Utilization Management (UM) Case Manager Tasks
Recommend process and policies to improve quality of patient services and increase revenue.
Analyze information gathered by investigation; report findings and recommendations.
Interview or correspond with physicians to correct errors or omissions and to investigate questionable claims.
Compile, audit and analyze patient records to document condition and treatment and to provide data for cost control and care improvement efforts.