Case Manager, RN - Utilization Review - PRN

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Job Description:

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Remote Eligibility: Candidates must reside and work full-time in AR, KS, MO, OK, or TX before their first day of employment. Please do not apply if you reside outside these 5 states and will not relocate to one of the approved states listed.

SHIFT: PRN

**PRN POSITIONS REQUIRE A MINIMUM OF 2 SHIFTS/MONTH**

The Utilization Review RN CM is a competent professional who excels in evaluating the medical necessity and appropriateness of healthcare services and treatments. They ensure patients receive appropriate care, working closely with insurance companies, patients, and interdisciplinary providers to secure authorizations for hospital stays or treatments. Utilizing clinical knowledge and evidence-based tools, the RN CM reviews and interprets medical records accurately, managing payor denials while maintaining patient satisfaction. With strong communication skills and advanced problem-solving abilities, using technology to safeguard HIPAA Protected Health Information.

Essential Responsibilities

Responsibilities listed in this section are core to the position. Inability to perform these responsibilities with or without an accommodation may result in disqualification from the position.

• Conduct comprehensive assessments of patients' health status, medical history, and ongoing care needs utilizing Evidence based criteria tool.
• Coordinates with the Interdisciplinary healthcare team, Payors, patients and families to ensure appropriate status and Financial reimbursement.
• Provides education to patients and their families regarding their healthcare stay and appropriate status in compliance with mandated regulatory and financial expectations.
• Coordinates and facilitates communication between patients, families, healthcare providers, and Payor sources to optimize appropriate patient and healthcare system financial reimbursement outcomes.
• Evaluates effectiveness of Evidence based criteria tool and Payor platforms identifying issues and escalates to Leadership to facilitate adjustments needed. 
• Evaluate healthcare utilization patterns and identify opportunities for improving efficiency and cost-effectiveness based on Payor contracts and Healthcare Mandated regulatory guidelines.
• Advocates for and Demonstrates use of appropriate criteria status to meet patient and system needs while adhering to regulatory guidelines and reimbursement criteria. 
• Collaborates with insurance providers, Interdisciplinary teams, and other stakeholders to ensure timely authorization of services and coverage for patient hospital care and treatment.
• Monitors and evaluates patient and healthcare system financial outcomes and processes to identify areas for improvement and escalates issues to Leadership.
• Participates in quality improvement initiatives and interdisciplinary care conferences to promote evidence-based practices and enhance patient safety and satisfaction. 
• Ensures compliance with federal, state, and local regulations, as well as accreditation requirements related to Nursing care management and patient continuum of care.  
• Implements approved strategies to minimize readmissions, prevent financial complications, and optimizes appropriate financial reimbursement processes.
• Precepts newly hired Nursing Utilization Review care managers.
• Participates in departmental activities such as secondary case review, policy maintenance, quality and/or performance improvement, and assigned workgroups.
• Maintains continuing Education with approved evidence-based criteria tool and Departments process competencies and participates in quality audit review findings.
• Maintains a HIPPA compliant work environment to protect Patient Protected Health Information while working from home. Must provide secure Internet and Cellular phone services.
• Performs other duties as needed.
• Lead Care Management team meetings and interdisciplinary rounds.
• Complete Leadership academy leadership classes as assigned.

General Responsibilities

• Performs other duties as assigned.

Minimum Qualifications

Education Requirements

• Bachelor's Degree in Nursing required.
   

Experience Requirements

• At least 3 years of Nursing experience required, with Care Management experience preferred.

License/Certification/Registration Requirements

• Current Registered Nurse License (RN License issued by the Oklahoma State Board of Nursing, or a current multistate compact Registered Nurse (eNLC)).

Knowledge/Skills/Abilities Required

• Demonstrates expertise in regulatory requirements regarding the Utilization Review care management discipline. 
• Strong communication, interpersonal, and leadership skills.
• Detailed- oriented with excellent organizational skills.
• Commitment to fostering a culture of continuous learning, quality improvement, and patient-centered care.
• Strong assessment, critical thinking, and problem-solving skills 
• Strong knowledge of healthcare regulations, including CMS guidelines and Payor Contractual agreements.
• Show clear understanding of utilization management principles and integrate these with Nursing care management responsibilities.
• Serve as liaison between patients, families, Payors and healthcare providers. 
• Demonstrates HIPPA compliance in a Work from home environment to safeguard PHI.
• Proficiency in utilizing electronic health records (EHR) and care management software
• Strong assessment, critical thinking, and problem-solving skills.

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OU Health is an equal opportunity employer. We offer a comprehensive benefits package, including PTO, 401(k), medical and dental plans, and many more. We know that a total benefits and compensation package, designed to meet your specific needs both inside and outside of the work environment, create peace of mind for you and your family.