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Registered Nurse Case Manager Utilization Review- Tampa, FL

Moffitt Cancer Center

Last Updated: 6/01/23

Job Description

At Moffitt Cancer Center, we come face-to-face with cancer every day, but we also see courage. And it inspires us to be the safest and best place for cancer care – to bring greater hope to every patient we serve.
It’s why we’ve been continually named One of the Top Places to Work in the Tampa Bay Area. As the only National Cancer Institute-designated Comprehensive Cancer Center based in Florida, Moffitt employs some of the best and brightest minds from around the world. Moffitt is the leading cancer hospital in both Florida and the Southeast and has been nationally ranked by U.S. News & World Report since 1999. Because working at Moffitt is both a career and a mission: to contribute to the prevention and cure of cancer.

As an important member of the multi-disciplinary care team, the Case Manager acts as a patient advocate by coordinating the care and service of patient populations across the continuum of care; promote effective utilization and monitoring of health care resources by collaborating with the health care team; maintain accurate knowledge of federal, state and payer standards; and assume a leadership role with the interdisciplinary team to achieve optimal clinical and resource outcomes. Core processes include risk assessment and management of clinical populations, discharge planning and utilization management.

Moffitt Values:

At Moffitt, our patients always come first.

The Moffitt Values reflect who we are and how we will continue to make an impact in the lives of those affected by cancer. Below is the list of Moffitt Values with corresponding examples of competencies which you will be evaluated on during the annual review period.

Compassion: We deliver hope; empowering and encouraging those we serve, and those who serve.

  • Consistently demonstrates the principles of dignity and respect, information sharing, active listening, and collaboration.
  • Consistently acts with the team member/customer/patient in mind, demonstrates care and concern for others and establishes and maintains the trust and respect of internal and/or external
  • Communicates effectively and Uses good judgment as to what to communicate to whom as well as the best method to get the communication purpose accomplished.
  • Promotes positive team environment by cooperating with team members to resolve problems and achieve goals.
  • Anticipates needs or problems and acts to meet or resolve responsibly, efficiently, and

Drive: We are courageous and determined in the relentless pursuit of our purpose, because whenever lose sight of those who depend on us.

  • Actively engages in activities that support the organization's mission and goals, prioritizing efforts, identifying barriers, and seeking solutions.
  • Motivates and inspires, takes appropriate action, and demonstrates determination when seizing upon opportunities or meeting challenges.
  • Fosters cooperation and seeks opportunities to support team efforts, even if not directly assigned to them.
  • Shares skills/knowledge with others by mentoring, coaching, teaching, or active committee
  • Actively seeks out opportunities for learning, growth and self-improvement that add value to the

Excellence: We strive for global impact through perseverance and persistence, and never settle for anything but our best.

  • Consistently demonstrates and promotes the highest standards of quality in organizational processes and systems of the organization.
  • Seeks opportunities to provide service, resolve problems, and contribute to organizational
  • Supports a culture of accountability by managing time and workload effectively and responding quickly and constructively when confronted with challenges.
  • Works in a cooperative and collaborative manner that leverages the strengths of others to accomplish goals.

Imagination: We are bold in our pursuit of new and better ways to transform health, wellness and healing.

  • Exhibits a problem-solving attitude; seeks ways to improve processes, increase efficiency, and find solutions to current situations or to develop new methods and procedures.
  • Generates new and innovative ideas, concepts, projects, and other practices for doing things more effectively to create value.
  • Respectfully challenges the status quo to seek creative solutions and novel
  • Embraces change, keeps an open mind and values

Inclusion: We are a diverse and unified team, which strengthens us, and fosters the trust, respect and collaboration that is core to our being.

  • Efficiently, effectively, and constructively employ mutually beneficial solutions for all concerned parties, treating others fairly and ensuring equity in decision making and conduct.
  • Continuously examines own assumptions and expectations with an awareness of shared and different perspectives and goals.
  • Seeks out, acknowledges, and values the opinions and contributions of others, incorporating diverse perspectives and insights in team building, group collaborations, project work, and idea

Demonstrates respect for people of differing backgrounds, viewpoints, needs, and experiences, and fosters a sense of belonging by building trust, regarding uniqueness, and respecting diversity.

To deliver individualized quality nursing care to cancer patients and families in accordance with established hospital guidelines, nursing professional practice model, nursing care standards and policies and in accordance with ANA code of ethics and external regulatory agencies.

Registered Nurses embody the vision, mission, and philosophy of Moffitt Nursing and are committed to and accountable for personalized patient and family centered care and the concepts of Duffy's quality caring model/caring factors. These frameworks of care include:

  • Collaboration and mutual problem solving, dignity and human respect, encouraging manner, attentive reassurance, appreciation of unique meaning, healing environment, basic human needs, information sharing, caring for self, and affiliation needs.

Registered Nurses use the nursing process to effectively plan and manage quality patient care. Biophysical, psychosocial, environmental, self-care, educational and discharge planning needs are addressed in all steps of the nursing process. This is demonstrated in baseline and comparative documentation, entered in a timely manner, and with evidence of age-appropriate consideration when care is planned, delivered, and evaluated.

The Professional Practice Model graphic and Duffy's caring factors are attached.

Essential Function: Discharge Planning Job Specific Duties:

  • Using established criteria (InterQual), reviews appropriateness of patient admission, need for continued stay, and information needed for discharge.
  • Discuss estimated length of stay vs GMLOS, treatment and discharge plan with physician, as indicated.
  • Initiate discharge plan within 24 hours of admission by assessing patient needs and documenting assessment in the patient record. This includes interviewing the patient, family, and appropriate health care team members to develop discharge plan that incorporates patient choice, and is clinically appropriate, cost-effective, and safe.
  • Ensure that the interdisciplinary care plan and the discharge plan are consistent with the patient's clinical course, continued care needs and covered services.
  • Refers complex discharge plan issues to other members of the Case Management team, to include the Physician Advisor as directed by referring criteria.
  • Provide leadership and guidance to the health care team to implement the discharge plan and facilitate patient transfer to the next level of care when medically able.
  • Participate in daily Interdisciplinary Rounds or other patient conferences.
  • Discuss with Physician and/or Physician Advisor the appropriateness of resource utilization, consultation, and treatment plan.
  • Coordinate appropriate education/instruction for patients, families, and other health care staff to accomplish positive patient care outcomes.
  • Identify possible delays in care and avoidable days; work with other health care team members to prevent delays and identify system/provider opportunities for improvement.
  • Initiate Condition Code 44 when appropriate following the established protocol.
  • Other duties as assigned.

Essential Function: Utilization Management Job Specific Duties:

  • As part of the interdisciplinary team, determines medical necessity of all admissions and continued stays in the hospital as well correct patient classification and efficient use of resources in accordance with state and federal regulations and the Hospital's Utilization Management Plan.
  • Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria (InterQual), and third-party information.
  • Intervenes when determinations are not in alignment with clinical information, clinical criteria (InterQual) or third-party information to resolve the situation.
  • Documents all Case Management interventions in current electronic system.
  • Refers, all unjustified cases and identified variances to the Physician Advisor for resolution within appropriate time frame.
  • All new admission reviews are to be completed within 24 hours of admission or within one business day, where appropriate.
  • Validates admission and continued stays with third party payers as well as the attending Physicians. InterQual criteria is to be utilized with all admission and continued stay reviews as well as with each denial. All concurrent reviews are to be completed every other day, unless specified otherwise by the payer.
  • Reviews are to include current medical status with supporting labs, study results, and treatments which are relevant to the level and acuity of care, procedures, surgeries, plan of care and patient progress towards goal.
  • Provide any contributing social, educational or discharge planning issues.
  • All requests from the payer are to be responded to on the day received or within one business day.
  • Contact and educate the physician when documentation does not support the medical necessity for acute level of care, or the admission was not pre-certified by the health plan.
  • Intervene to prevent denials when possible.
  • Support the effective prevention and management of denials, including providing requested information as part of the appeal process. Assures completion of any and all authorizations, as needed.
  • Work with Denial and Appeals Coordinator and Director on all denials, as needed. Maintain cost-effective utilization of care continuum resources.
  • Other duties as assigned.

Minimum Education Education Level:

Bachelor’s Degree in Nursing

  • Associates Degree in Nursing plus 1 year of experience of relevant Acute Case Management experience may be considered.

Minimum 5 years clinical experience in an Acute Care setting required.

Minimum 1 year case management/utilization review experience in an acute care setting required.

Must be able to work independently with minimal direction, anticipate and organize workflow, prioritize, and follow through on responsibilities.

  • BSN or MSN Preferred
  • ACM or CCM Certification
  • Demonstrated experience in oncology nursing
  • Extensive knowledge of nursing care, healthcare trends, community and healthcare resources
  • Knowledge of state and federal regulations governing discharge planning, utilization management, and other regulatory agency requirements by the Joint Commission and CMS strongly preferred.
  • Working knowledge of InterQual criteria preferred Strong interpersonal communication skills
  • Competent computer skills to include Cerner and Microsoft office products

Licensure and Certification: Minimum Required

Registered Nurse (RN)

RN-Current licensure as a Registered Nurse (RN) in the State of Florida, or a valid multi-State privilege to practice in the State of Florida (Must declare Florida as primary State of residence within 30 days from date of hire if licensed in another eNLC compact state with multi- state privileges.)

Basic Life Support (BLS)


Specific courses or certifications may be required for placement in specialty areas.

National Nursing specialty certifications

Service - Creates and sustains a service-oriented system that promotes partnerships and

    • Develops and maintains positive relationships with both internal and external
    • Conveys a positive image of Moffitt to customers by maintaining professional standards as outlined in MCC policies in their conduct, dress and verbal, written and non-verbal communications.
    • Consistently demonstrates superior customer service
    • Listens to customers to understand their needs and ensures they understand the information being provided to them.
    • Meets work deadlines as assigned and/or promptly communicates any issues with meeting deadlines as soon as they are known.
    • Promptly responds to written and verbal requests, assigning appropriate priorities to various work
    • Communicates effectively and Uses good judgment as to what to communicate to whom as well as the best method to get the communication purpose accomplished.
    • Speaks in a clear and credible manner, selecting the right tone for the situation and Listens to others and allows them to make their point.
  1. People - Creates and sustains a culture that promotes respect, trust, diversity, accountability, teamwork and professional
    • Works efficiently, effectively and constructively to find mutually beneficial solutions for all concerned
    • Shares knowledge and expertise with others to ensure the success of team and individual
    • Supports coworkers by maintaining attendance and punctuality
    • Commits to the principles of dignity & respect, information sharing, participation and collaboration when dealing with others.
    • Demonstrates accountability for actions, choices and outcomes; answers for own conduct and
  2. Innovation - Focuses on innovations that will reshape traditional models and
    • Demonstrates willingness to adapt to changing individual and institutional roles, processes, needs and
    • Exhibits a problem solving attitude; constantly seeks ways to improve processes, increase efficiency, finds solutions to current situations or to develop new methods and procedures.
    • Works in partnership with team members and patient and family advisors to improve processes or
  3. Quality - Focuses on quality of patient care, research, and
    • Consistently provides quality products/services as defined by department standards and/or individual job
    • Possesses sufficient job skills and knowledge to perform the job in a competent Is able to demonstrate skills and knowledge in day-to-day situations.
    • Projects pride in work as exhibited in day-to-day interactions with team members, patients and all those they come in contact with.
    • Maintains awareness and follows safety policies and procedures applicable to assigned Uses sound judgment including reasonable awareness of potential hazards before acting.
    • Promptly reports errors, events or situations of actual or potential
  4. Growth - Supports growth and financial
    • Actively seeks learning/acquiring new skills through on-the job training/experience, self-study or facilitated
    • Demonstrates fiscal responsibility by not wasting resources (supplies, money, time); reuses, repurposes or recycles materials as appropriate.
    • Shares skills/knowledge with others by mentoring, coaching and active committee
    • Consistently meets department or individual standards for the quantity of work

Company Details

Tampa, Florida, United States
Be a part of Something Greater at Moffitt: At Moffitt Cancer Center, we come face-to-face with cancer every day, but we also see courage. And it inspires us to be the safest and best place for cancer care – to bring greater hope to every patient we serve. It’s why we’ve been continually named One of the Top Places to Work in the Tampa Bay Area. Working at Moffitt is both a caree...