Registered Nurse - Utilization Case Management

Utilization Case Management Registered Nurse – Case Management Department

Location:

Uvalde Memorial Hospital Job Type: Full-Time, Non-Exempt

Schedule:

Monday - Friday 8am-5pmCoordinate Care. Advocate for Patients. Create Smoother Transitions.

At Uvalde Memorial Hospital, exceptional care extends beyond a patient’s hospital stay. We are seeking a compassionate and experienced Case Management Registered Nurse to help patients receive the right care, at the right time, while preparing them and their families for a safe and successful transition after  this role, you’ll combine clinical expertise, critical thinking, care coordination, and patient advocacy. You’ll work closely with physicians, nurses, social workers, therapists, payers, and community resources to support appropriate utilization of healthcare services, reduce unnecessary hospital stays, and develop individualized discharge plans that meet each patient’s  This Role, You Will:

Perform utilization reviews for admissions, continued stays, and services to evaluate medical necessity and appropriate use of healthcare resources.

Review care against clinical guidelines, payer requirements, and hospital protocols.

Maintain accurate documentation of utilization findings, care decisions, authorizations, and denials.

Identify opportunities to reduce unnecessary interventions and lengths of stay while maintaining quality patient care.

Complete comprehensive patient assessments that consider medical, psychosocial, and functional needs.

Develop individualized care and discharge plans in collaboration with the interdisciplinary healthcare team.

Begin discharge planning early in the patient’s hospitalization and continually evaluate readiness for the next level of care.

Coordinate post-discharge resources such as home health, rehabilitation, outpatient services, physical therapy, and durable medical equipment.

Work with insurance providers to facilitate authorizations and help ensure services meet payer requirements.

Educate patients and families about care plans, treatment needs, medications, discharge instructions, and follow-up care.

Advocate for patients and help identify and address barriers that could affect a safe discharge.

Collaborate with physicians, nursing staff, social workers, therapists, and other team members to promote continuity of care.

Provide leadership with timely updates regarding utilization patterns, patient progress, discharge efficiency, and outcomes.

Participate in quality improvement initiatives focused on reducing readmissions, improving care delivery, and strengthening discharge processes.

Maintain compliance with HIPAA, The Joint Commission, federal and state regulations, hospital policies, and other applicable standards.

What We’re Looking For:

Active Texas Registered Nurse (RN) license required.

Bachelor of Science in Nursing (BSN) strongly preferred.

Current Basic Life Support (BLS) certification required.

Certification in Case Management (CCM) or Accredited Case Manager (ACM) required within 24 months of hire.

Additional relevant certifications, such as Certified Discharge Planner, are a plus.

Two to five years of acute care clinical nursing experience, preferably involving case management, utilization review, or discharge planning in a hospital setting.

Strong clinical assessment, critical thinking, and problem-solving abilities.

Excellent communication and interpersonal skills when working with patients, families, providers, and interdisciplinary teams.

Strong organizational skills with the ability to manage multiple cases, documentation requirements, and follow-up needs.

Understanding of hospital operations, clinical guidelines, medical necessity criteria, and payer requirements, including Medicare, Medicaid, and private…