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Utilization Case Manager Jobs in Mississippi (NOW HIRING)

FMOLHS

Experienced Case Manager - RN

Jackson, MS

The Case Manager directs the utilization review of patient charts, treatment plans, and discharge planning pertaining to the quality of care and treatment criteria for patients in a specific ...

Forrest General Hospital

CASE MANAGER

Hattiesburg, MS · On-site

$16.75 - $21.50/hr

Case managers also play a key role in discharge planning and utilization review, helping patients access appropriate resources and services. Essential Functions: * The case manager plans, coordinates ...

Forrest General Hospital

CASE MANAGER

Hattiesburg, MS · On-site

$16.75 - $21.50/hr

Case managers also play a key role in discharge planning and utilization review, helping patients access appropriate resources and services. Essential Functions: * The case manager plans, coordinates ...

University of Mississippi

Case Manager

Oxford, MS · On-site

$46K - $70K/yr

Performs case management, utilization review, quality assurance, and care planning, including assessment, identification of specific needs, and social service intervention within the University.

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Utilization Case Manager information

What is a utilization case manager?

A Utilization Case Manager is a healthcare professional responsible for evaluating the necessity, appropriateness, and efficiency of medical services provided to patients. They review patient cases, coordinate with healthcare providers, and ensure that treatments are in line with established guidelines and insurance requirements. Their goal is to optimize patient outcomes while managing costs and ensuring compliance with regulations. Utilization Case Managers often work in hospitals, insurance companies, or managed care organizations.

How does a utilization case manager typically collaborate with healthcare providers and insurance companies?

Utilization Case Managers play a key role in coordinating care between healthcare providers and insurance companies. They review patient cases to ensure that the recommended treatments are medically necessary and align with insurance policies. This often involves regular communication with doctors, nurses, and insurance representatives to gather information, clarify treatment plans, and advocate for appropriate patient care. Strong collaboration skills are essential, as Utilization Case Managers must balance the needs of patients with organizational guidelines while maintaining positive professional relationships.

What degree do I need for utilization review?

Utilization case managers typically need at least a bachelor's degree in healthcare, nursing, social work, or a related field. Some positions may require a master's degree or professional certification, such as a Certified Case Manager (CCM) or Certified Professional in Healthcare Quality (CPHQ), to advance in the role or handle complex cases.

What are the key skills and qualifications needed to thrive as a utilization case manager?

To thrive as a Utilization Case Manager, you need a background in nursing or social work, strong analytical skills, and a solid understanding of healthcare regulations and insurance processes, often supported by RN licensure or certification in case management (e.g., CCM). Familiarity with utilization management software, electronic health records (EHRs), and payer authorization systems is essential. Excellent communication, critical thinking, and negotiation skills help facilitate collaboration among patients, providers, and payers. These skills ensure appropriate care delivery, cost management, and compliance with healthcare standards.

What is the difference between Utilization Case Manager vs Utilization Review Nurse?

AspectUtilization Case ManagerUtilization Review Nurse
CredentialsRN license, case management certificationRN license, certification in utilization review
Work EnvironmentCase management teams, hospitals, insurance companiesUtilization review departments, hospitals, insurance providers
Primary FocusCoordinating patient care, discharge planning, resource allocationAssessing medical necessity, reviewing patient records for appropriateness
Common UsageBroader case management roles, patient advocacySpecific review of medical necessity and insurance claims

While both roles require RN licensure and focus on patient care, the Utilization Case Manager primarily coordinates overall patient services and discharge planning, whereas the Utilization Review Nurse concentrates on evaluating the medical necessity of treatments for insurance purposes. Understanding these distinctions helps in choosing the right career path or job search focus.

What are popular job titles related to Utilization Case Manager jobs in Mississippi? For Utilization Case Manager jobs in Mississippi, the most frequently searched job titles are:
What job categories do people searching Utilization Case Manager jobs in Mississippi look for? The top searched job categories for Utilization Case Manager jobs in Mississippi are:
What cities in Mississippi are hiring for Utilization Case Manager jobs? Cities in Mississippi with the most Utilization Case Manager job openings:
Utilization Case Manager jobs near you

Experienced Case Manager RN - Case Management (Full Time, Days)

Franciscan Missionaries of Our Lady Health System

Jackson, MS • On-site

Other

Re-posted 17 days ago

Franciscan Missionaries of Our Lady Health System rating

7.2

Company rating: 7.2 out of 10

Based on 38 frontline employees who took The Breakroom Quiz

344th of 887 rated healthcare providers

Job description


The Case Manager directs the utilization review of patient charts, treatment plans, and discharge planning pertaining to the quality of care and treatment criteria for patients in a specific department. The Case Manager 1 specializes in the review of information pertaining specifically to the assigned areas. Relies on education, experience, professional training and judgment to accomplish responsibilities. A wide degree of creativity and latitude is expected. Works under minimal supervision. Directs the utilization review of patient charts and treatment plans pertaining to the quality of care and treatment criteria for patients in a specific department. The Case Manager of Clinical Services specializes in the review of information pertaining specifically to the assigned area (i.e.: Case Management, Geriatrics, Mental & Behavioral Health, Home Health). Most, but not all, of the accountabilities below may apply to each specific area.
Responsibilities
  1. Evaluation and Analysis:
    1. Contributes to cost effectiveness/efficiency and demonstrates awareness of benefit system and cost benefit analysis. Demonstrates the ability to maximize financial outcomes of assigned patient load using the continuum of care philosophy. Assists in the development, monitoring, and analysis of annual financial goals of targeted population.
    2. Understands the capabilities of outside referral sources such as home health, sub-acute care and skilled nursing facilities. Understands the different types of healthcare delivery systems and the requirements for prior approval by payor for admissions, procedures, and continued stay.
    3. Meets with treatment team to provide utilization review information, discusses issues pertaining to continued stay, discharge and aftercare plans, evaluates current financial resources, and discusses whether documentation reflects the need for continued stay and at what level of care is the most appropriate.
  2. Partnership and Collaboration
    1. Performs effective utilization review techniques to work with physicians, third party payors, and federal and local agencies to prevent denials of payment or days.
    2. Acts as a resource for unit personnel in the resolution of utilization/case management problems and expediently communicates identified problems to appropriate personnel in an effort to enhance departmental operating efficiency.
    3. Collaborates with all members of the health team to ensure reimbursement optimization, appropriate discharge planning, and cost-effective quality care. Plays a key role in the discharge planning process assessing patient's needs for referrals and/or alternate levels of care. Appropriately tracks and reports avoidable days.
    4. Demonstrates competence in coordination and service delivery. Understands methods for assessing an individual's level of physical/mental impairment. Assesses patient clinical information and in collaboration with the healthcare team, develops treatment/discharge plans.
  3. Quality
    1. Evaluates the quality of necessary medical services, utilizes criteria to determine medical necessity of admission and interacts with physicians to facilitate patient assignment to appropriate alternative of care.
    2. Provides appropriate and timely information to third party payors to facilitate financial outcomes and ensures patients are receiving appropriate level of care; includes coordinating denials/appeals.
    3. Demonstrates ability to access and utilize community resources. Is knowledgeable of the ADA and other federal legislation affecting individuals with disabilities. Knows how to establish a client support system.
    4. Observes and adheres to all departmental and hospital policies and procedures, and follows all safety, quality assurance, and infection control standards.
    5. Promotes the quality and efficiency of his/her own performance by remaining current with the latest trends in field of expertise through participation in job-relevant seminars and workshops, attendance at professional conferences, and affiliations with national and state professional organizations.
  4. Other Duties as Assigned
    1. Performs other duties as assigned or requested.

Qualifications
  • Graduate from an accredited school of nursing, RN.Minimum of two years' clinical experience required. Case management or Utilization management experience preferred. Employee must demonstrate ability to recognize patients' individual needs based on medical conditions, age (infants, pediatrics, adolescents, young adults, middle-aged and geriatric), limitations and planned procedures. Requires oral and written communication skills; professional affiliations.Current Mississippi RN license required.

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About Franciscan Missionaries of Our Lady Health System

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The Franciscan Missionaries of Our Lady Health System is the leading health care innovator in Louisiana. We bring together outstanding clinicians, the most advanced technology and leading research to ensure that our patients receive the highest quality and safest care possible.

Industry

Hospitals

Company size

5,001 - 10,000 Employees

Headquarters location

Baton Rouge, LA, US

Year founded

1911

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