The Utilization Review Case Manager is responsible for assessing the medical necessity, appropriateness, and efficiency of patient care services. Utilizing evidence-based clinical criteria such as InterQual, MCG, and the CMS Two-Midnight Rule. The UR Case Manager performs initial, concurrent, and retrospective reviews to ensure accurate patient status, appropriate level of care, and optimal length of stay. In this role, the UR Case Manager collaborates closely with physicians, care coordinators, payers, and the interdisciplinary care team to secure timely authorizations, optimize utilization of hospital resources, and support high-quality, patient-centered outcomes. The UR Case Manager proactively identifies barriers to discharge, monitors patient progression, and helps reduce denials through precise documentation and effective communication. The incumbent requires strong clinical judgment, critical thinking, and communication skills, along with the ability to work both independently and collaboratively in a fast-paced, multidisciplinary environment. Serving as a key liaison between the clinical team and payers, the UR Case Manager plays a vital role in ensuring regulatory compliance, appropriate reimbursement, and safe, efficient, patient-centered care.

Originally posted on Himalayas