Case Manager, RN - Utilization Review - PRN

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.

** 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.

• 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 work groups.
• 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.

• Performs other duties as assigned.

• 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)).

• Demonstrates expertise in regulatory requirements regarding the Utilization Review care management discipline.
• Strong communication, interpersonal, and leadership skills.
• Detailed- oriented with excellent…