RN Case Manager – Utilization Review

This is a fully remote position, open to applicants in Oklahoma.

📋 Description

• Conduct thorough evaluations of patients’ clinical, psychological, and financial requirements.

• Suggest and organize timely transfers to suitable levels of care.

• Create, execute, assess, and modify discharge plans, including referrals.

• Relay discharge care plans and updates to patients, families, and healthcare professionals.

• Support physicians and hospital personnel with resource utilization and efficient discharge planning.

• Coordinate services among hospital departments to streamline patient discharge.

• Perform concurrent reviews of patient records.

• Utilize criteria to assess appropriate resource utilization.

• Inform internal and external parties about utilization issues impacting patient care or reimbursement.

• Oversee patient transfers in accordance with hospital policies and relevant regulations.

• Counsel physicians on discharge planning, documentation, resource usage, and reimbursement.

• Manage established pathways to improve clinical effectiveness and resource management.

• Stay informed about CMS, Medicare, Medicaid, managed care, payer regulations, and benefit restrictions.

• Educate patients, families, and healthcare professionals regarding payer regulations and benefits.

• Build knowledge of hospital and community resources and facilitate suitable levels of care.

• Identify opportunities to minimize care-management expenses without compromising quality or outcomes.

• Gather and document data for utilization and Quality Improvement reporting.

• Collaborate with patients, families, physicians, hospital staff, and other care organizations.

⛳️ Requirements

• Minimum of 2 years of experience in a clinical environment, such as home health, inpatient, physician office, or clinic.

• BLS (Basic Life Support) certification from the American Red Cross or American Heart Association to be obtained within 30 days of hire.

• Active Registered Nurse (RN) licensure in the State of Oklahoma or a current multistate license from a Nurse Licensure Compact (eNLC) member state.

• Strong interpersonal communication and collaboration abilities.

• Proficient in computer skills.

• Effective communication skills in English, both verbal and written.

• Valid Oklahoma State Driver's License.

• Driving history that meets the employer's insurance carrier's standards.

• Preferred experience with managed care and payer/provider requirements.

• Bachelor's degree in Nursing preferred.

• Case Management Certification is preferred.

🏝️ Benefits

• Front-loaded PTO.

• Medical benefits through the extensive INTEGRIS Health network.

• Financial support for ongoing education.

• 24/7 mental health assistance.