Remote Utilization Review RN Case Manager (PRN)

NurseRemotely; United States; Remote; USD 85,000 - 110,000; Full time

Benefits offered by this job

PTO

401(k)

Medical plan

Dental plan

Job summary

OU Health is seeking a Case Manager, RN - Utilization Review (PRN) to evaluate medical necessity and appropriate care, securing authorizations and coordinating with payors, patients, and interdisciplinary teams. This role emphasizes HIPAA compliance and strong communication across stakeholders for optimal financial reimbursement.

The candidate will review medical records, apply evidence-based criteria, and participate in quality improvement initiatives while maintaining regulatory alignment and

Qualifications

• Bachelor's Degree in Nursing required.
• 3+ years nursing experience required; care management experience preferred.
• Current RN license (OK state or multi-state compact).

Responsibilities

• Conduct comprehensive assessments of patients' health status, medical history, and ongoing care needs utilizing Evidence based criteria tool.
• Coordinates with the Interdisciplinary healthcare team, Payors, patients and families to ensure appropriate status and Financial reimbursement.
• Provides education to patients and their families regarding their healthcare stay and appropriate status in compliance with mandated regulatory and financial expectations.
• Coordinates and facilitates communication between patients, families, healthcare providers, and Payor sources to optimize appropriate patient and healthcare system financial reimbursement outcomes.
• Evaluates effectiveness of Evidence based criteria tool and Payor platforms identifying issues and escalates to Leadership to facilitate adjustments needed.
• Evaluate healthcare utilization patterns and identify opportunities for improving efficiency and cost-effectiveness based on Payor contracts and Healthcare Mandated regulatory guidelines.
• Advocates for and Demonstrates use of appropriate criteria status to meet patient and system needs while adhering to regulatory guidelines and reimbursement criteria.
• Collaborates with insurance providers, Interdisciplinary teams, and other stakeholders to ensure timely authorization of services and coverage for patient hospital care and treatment.
• Monitors and evaluates patient and healthcare system financial outcomes and processes to identify areas for improvement and escalates issues to Leadership.
• Participates in quality improvement initiatives and interdisciplinary care conferences to promote evidence-based practices and enhance patient safety and satisfaction.
• Ensures compliance with federal, state, and local regulations, as well as accreditation requirements related to Nursing care management and patient continuum of care.
• Implements approved strategies to minimize readmissions, prevent financial complications, and optimizes appropriate financial reimbursement processes.
• Precepts newly hired Nursing Utilization Review care managers.
• Participates in departmental activities such as secondary case review, policy maintenance, quality and/or performance improvement, and assigned workgroups.
• Maintains continuing Education with approved evidence-based criteria tool and Departments process competencies and participates in quality audit review findings.
• Maintains a HIPPA compliant work environment to protect Patient Protected Health Information while working from home. Must provide secure Internet and Cellular phone services.
• Performs other duties as needed.
• Lead Care Management team meetings and interdisciplinary rounds.
• Complete Leadership academy leadership classes as assigned.

Skills

Regulatory knowledge

Leadership

Communication

Detail-oriented

Problem solving

HIPAA compliance

Education

Bachelor's Degree in Nursing

Tools

EHR systems

Care management software

Job description

OU Health is seeking a Case Manager, RN - Utilization Review (PRN) to evaluate medical necessity and appropriate care, securing authorizations and coordinating with payors, patients, and interdisciplinary teams. This role emphasizes HIPAA compliance and strong communication across stakeholders for optimal financial reimbursement.

The candidate will review medical records, apply evidence-based criteria, and participate in quality improvement initiatives while maintaining regulatory alignment and