Case Manager, RN – Utilization Review

This is a fully remote position, open to applicants in Kansas, +3 more states.

📋 Description

• Conduct thorough evaluations of patients' health conditions, medical backgrounds, and ongoing care requirements using evidence-based criteria tools.

• Collaborate with interdisciplinary healthcare teams, payors, patients, and their families to ensure appropriate status and financial reimbursement.

• Provide education to patients and their families regarding healthcare admissions and appropriate status.

• Facilitate communication among patients, families, healthcare providers, and payors.

• Assess evidence-based criteria tools and payor platforms; identify challenges and escalate them to leadership.

• Analyze healthcare utilization trends and pinpoint opportunities to enhance efficiency and cost-effectiveness.

• Ensure prompt authorization of services and coverage for hospital care and treatments.

• Monitor financial outcomes and processes related to patients and the healthcare system.

• Engage in quality improvement initiatives and interdisciplinary care conferences.

• Ensure adherence to federal, state, and local regulations, as well as accreditation standards.

• Implement strategies aimed at reducing readmission rates and preventing financial complications.

• Precept newly hired Nursing Utilization Review care managers.

• Participate in secondary case reviews, policy updates, quality/performance improvement, and designated workgroups.

• Maintain ongoing education, process competencies, and involvement in quality audit reviews.

• Uphold a HIPAA-compliant work environment while working remotely.

• Lead Care Management team meetings and interdisciplinary rounds.

• Complete assigned Leadership Academy courses.

• Perform additional duties as assigned.

⛳️ Requirements

• Candidates must reside and work full-time in Arkansas, Kansas, Missouri, Oklahoma, or Texas prior to their start date.

• PRN positions necessitate a minimum of 2 shifts per month.

• A Bachelor's Degree in Nursing is required.

• A minimum of 3 years of Nursing experience is required; Care Management experience is preferred.

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

• Proficiency in regulatory requirements related to Utilization Review care management.

• Strong communication, interpersonal, and leadership abilities.

• Exceptional organizational skills and attention to detail.

• Strong assessment, critical thinking, and problem-solving capabilities.

• Familiarity with healthcare regulations, including CMS guidelines and Payor Contractual agreements.

• Understanding of utilization management principles and Nursing care management responsibilities.

• Compliance with HIPAA work-from-home practices to protect PHI.

• Proficiency in electronic health records (EHR) and care management software.

• Must provide secure internet and cellular phone services.

🏝️ Benefits

• Paid time off (PTO).

• 401(k) plan.

• Medical insurance plans.

• Dental insurance plans.

• Comprehensive benefits and compensation package.

• Secure internet and cellular phone services required for remote work.