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, implement, assess, and modify discharge plans, including referrals to healthcare and community organizations.

• Communicate discharge care plans and any changes to patients, their families, and healthcare professionals.

• Support physicians and hospital staff with resource allocation and timely discharge planning.

• Coordinate services among hospital departments to ensure timely discharge.

• Perform concurrent reviews of patient records.

• Utilize criteria to assess appropriate resource allocation.

• Inform internal and external stakeholders about utilization issues that could impact patient care or reimbursement.

• Facilitate patient transfers to other healthcare organizations in accordance with policies and regulations.

• Advise physicians on discharge planning, medical-record documentation, resource utilization, and reimbursement matters.

• Stay updated on CMS, Medicare/Medicaid, managed care, payer regulations, and benefit limits.

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

• Build knowledge of hospital and community resources to ensure appropriate levels of care.

• Identify opportunities to decrease care-management costs while maintaining quality and outcomes.

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

• Collaborate effectively with patients, families, physicians, hospital staff, and external agencies.

⛳️ Requirements

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

• Valid RN license in Oklahoma or a current multistate license from an eNLC member state.

• BLS certification from the American Red Cross or American Heart Association within 30 days of employment.

• Strong interpersonal communication and collaboration abilities.

• Proficient in computer usage.

• Familiarity with managed care and payer/provider requirements.

• Bachelor of Science in Nursing degree.

• Certification in Case Management.

🏝️ Benefits

• Front-loaded paid time off (PTO).

• Comprehensive medical benefits through the extensive INTEGRIS Health network.

• Financial support for ongoing education.

• 24/7 mental health assistance.