Case Manager - Utilization Review

OU Health; United States; On-site; USD 65,000 - 85,000; Full time

Job summary

A leading healthcare provider seeks an experienced RN for conducting timely medical necessity reviews using established criteria and collaborating with the healthcare team. The ideal candidate will have at least three years of nursing experience in acute care, strong clinical assessment skills, and the ability to work independently. Knowledge of insurance and regulatory requirements is preferred. This role offers opportunities for professional growth in a supportive environment.

Qualifications

• Three years of clinical nursing experience in an acute care facility.
• Experience with utilization review or case management preferred.
• Current RN License issued by the Oklahoma State Board of Nursing.

Responsibilities

• Conduct timely medical necessity reviews for all patients.
• Communicate with insurance companies and healthcare team.
• Review insurance denials and attempt to get them overturned.

Skills

Clinical assessment skills

Critical thinking skills

Knowledge of insurance terminology

Basic computer skills

Interpersonal and communication skills

Education

Graduate from an accredited school of nursing

Bachelor of Science in Nursing

Job description

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.

• 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 healthcare services administered to the patients are of the highest quality, yet cost-efficient and in compliance with current regulations.
• Complete continuous review and audit of the patients' treatment records 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 physicians.
• Follow HIPAA 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.
• Attend meetings online or in person as required.

Responsibilities:

• Perform other duties as assigned.

Education: Graduate from an accredited 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.
• 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 promote team concepts.

OU Health is an equal opportunity employer.