RN Case Manager - Utilization Review

General Description: Conducts Timely Medical necessity review for patients using nationally accepted criteria to determine appropriateness of admission and level of care. Communicates with insurance companies and members of the care team as needed using critical thinking skills, clinical expertise, and sound medical judgement

Essential Responsibilities:

• Conduct timely medical necessity reviews for all patients using medical coverage guideline (MCG) criteria to determine appropriateness of admission and level of care.
• Present all cases that do not meet Clinical criteria, questionable admissions, and prolonged lengths of stays to the Medical Director for determination.
• Frequent correspondence with payers to ensure clinical review is sent to payers in a timely manner.
• Ensure that the health care services administered to the patients in the highest quality yet at the same time cost-efficient and in compliance with the current regulations
• Complete continuous review and audit of the patients treatment record to prevent unnecessary procedures, ineffective treatment, and unnecessary extensive hospital stays
• Use critical thinking skills, clinical expertise, and judgement along with established medical criteria to provide a recommendation of level of care to physician
• Follow HIPPA guidelines for patient privacy
• Review charts to ensure documentation and medical necessity meet Medicare regulations
• Review insurance denials and attempt to get them overturned
• Communicate with members of the Healthcare team
• Create reports out of system as needed
• Utilize various computer applications
• Attend meetings online or in person as required.

General Responsibilities:

• Perform other duties as assigned.

Minimum Requirements:

Education: Graduate from an accredited school school of nursing required. Bachelor of Science (or higher) in Nursing Board Approved Program preferred.

Experience: Three (3) years clinical nursing experience in an acute care facility. Experience with utilization review or case management preferred. MCG experience preferred.

Licensure/Certifications/Registrations Required: Current RN License issued by the Oklahoma State Board of Nursing, or a current multistate Compact RN License (eNLC). Case management certification preferred.

Knowledge, Skills & Abilities:

• Knowledge of nursing practices and procedures
• Strong clinical assessment skills and critical thinking skills
• Requires knowledge of third party payer issues concerning reimbursement and regulatory perimeters.
• Must be proficient with basic computer skills. (Microsoft Office products)
• Knowledge of insurance terminology and Medicare guidelines
• Excellent typing skills
• Ability to work independently, manage time and prioritize patient needs
• Ability to work under minimal supervision in a remote environment
• Able to work some weekends and holidays
• Able to adapt to frequent changes in direction
• Excellent interpersonal and communications skills with nursing staff, physicians, nurse practitioners and other health workers
• Ability to meet deadlines and manage multiple priorities, and effectively adapt and respond to complex, fast-paced, rapidly growing, and results-oriented environments
• Able to work in a dynamic, fast-paced team environment and to promote team concepts