Full Name: Degree (BSN, MSN, BSW, MSW, etc.) – University & Year: Current License (RN/LMSW/LCSW) – State & Status: Case Management Certification (CCM, ACM, etc.) (Yes/No – details): Total Case Management Experience (Years): Total Utilization Management / Discharge Planning Experience (Years): Total Hospital-Based Nursing or Social Work Experience (Years): Total Leadership Experience (Years): Do you have at least 5 years of Case Management / Utilization Management experience?