RN - Case Manager

Cynet Health; Austin (TX); On-site; USD 55,000 - 96,000; Full time

Job summary

Cynet Health is seeking a Registered Nurse Case Manager for a 13-week assignment in Austin, TX. This role focuses on utilization review, discharge planning, and complex case management, requiring 2+ years acute care UM experience and a TX RN license.

Proficiency with InterQual/MCG and CMS regulations is essential; familiarity with payer portals and managed Medicare/Medicaid insurers is a plus. Remote work experience is noted.

Qualifications

• Minimum 2 years acute care utilization management experience
• Licensed RN (TX or multi-state)
• BLS certification required
• Experience with case management and discharge planning is a plus
• Knowledge of InterQual/MCG and CMS guidelines

Responsibilities

• Provides health care services regarding admissions, case management, discharge planning, and utilization review.
• Reviews admissions and service requests for prospective, concurrent, and retrospective medical necessity and compliance with reimbursement policy criteria.
• Provides case management and consultation for complex cases.
• Assists departmental staff with issues related to coding, medical records, documentation, precertification, reimbursement, and claim denials or appeals.
• Assesses and coordinates discharge planning needs with healthcare team members.
• May prepare statistical analysis and utilization review reports as necessary.
• Oversees and coordinates compliance with federally mandated and third-party payer utilization management rules and regulations.
• Requires critical thinking skills, decisive judgment, and the ability to work with minimal supervision.
• Must be able to work in a stressful environment.

Skills

InterQual/MCG

CMS regulations

Remote work

Payer portals

Tools

Payer portals

Job description

RN - Case Manager

Profession: Registered Nurse

Specialty: Utilization Review

Duration: 13 Weeks

Shift: 08:30 AM - 05:00 PM

Hours per Shift: 8

Experience: Minimum of 2 years acute care utilization management experience

License: Licensed RN (multistate or TX RN)

Certifications: BLS

Must-Have:

Proficiency with InterQual/MCG and CMS regulations.Familiarity with payer portals and managed Medicare and Medicaid insurers.Proficient and adaptable with multiple technologies simultaneously.Remote work experience.

Description:

Provides health care services regarding admissions, case management, discharge planning, and utilization review.Reviews admissions and service requests for prospective, concurrent, and retrospective medical necessity and compliance with reimbursement policy criteria.Provides case management and consultation for complex cases.Assists departmental staff with issues related to coding, medical records, documentation, precertification, reimbursement, and claim denials or appeals.Assesses and coordinates discharge planning needs with healthcare team members.May prepare statistical analysis and utilization review reports as necessary.Oversees and coordinates compliance with federally mandated and third-party payer utilization management rules and regulations.Requires critical thinking skills, decisive judgment, and the ability to work with minimal supervision.Must be able to work in a stressful environment.