RN Case Manager

Clinical Management Consultants; Town of Texas (WI); On-site; USD 70,000 - 95,000; Full time

Job summary

Clinical Management Consultants in Wisconsin seeks an experienced RN Case Manager / Utilization Review Nurse to evaluate medical necessity and ensure appropriate care levels across prospective, concurrent, and post-discharge reviews. The role collaborates with physicians and care teams to resolve documentation issues and support accurate patient status determinations.

The position emphasizes denial management, discharge planning support, and utilization reporting.

Qualifications

• Active Texas RN license
• Current CPR certification
• BSN preferred
• Case management certification preferred
• 5+ years in case management, discharge planning, and utilization review

Responsibilities

• Evaluate medical necessity and ensure appropriate care levels using CMS and payer criteria.
• Perform prospective, concurrent, and post-discharge reviews.
• Assess admission status and monitor hospital stays.
• Support denial management through identifying denials and drafting appeal letters.
• Coordinate documentation and analyze payer trends to reduce denials.
• Assist with discharge planning and coordinate home health, equipment, meds, and therapies.
• Contribute to utilization reports, regulatory reviews, and staff education.

Skills

Critical thinking

Organization

Communication

Attention to detail

Education

BSN preferred

Job description

An exciting opportunity is available for an experienced RN Case Manager / Utilization Review Nurse to join a respected healthcare organization focused on quality, patient-centered care, and efficient care delivery. This role is ideal for a detail-oriented nursing professional who enjoys clinical review, problem-solving, and collaborating across the healthcare team.

The RN Case Manager / Utilization Review Nurse will play a key role in evaluating medical necessity and ensuring patients receive the appropriate level of care. This position will conduct prospective, concurrent, and post-discharge reviews using approved clinical criteria. The nurse will also evaluate admission status, monitor continued stays, and ensure documentation meets CMS, payer, and regulatory requirements.

The Utilization Review RN will work closely with physicians, case managers, physician advisors, and interdisciplinary teams to resolve documentation concerns and support accurate patient status determinations. A major focus of the role will be denial management. Responsibilities include identifying denials, preparing appeal letters, coordinating supporting documentation, and analyzing payer trends to help reduce future denials.

This RN Case Manager will also support discharge planning when needed. The nurse will help identify barriers to discharge and coordinate resources such as home health, durable medical equipment, medications, and therapy services. The role will also monitor avoidable days and extended lengths of stay while contributing to utilization reports, quality initiatives, regulatory reviews, and staff education.

Qualified candidates must hold an active Texas RN license and current CPR certification. A BSN is preferred along with case management certification. Candidates should have at least five years of experience in case management, discharge planning, and utilization review. Strong critical thinking, organization, communication, and attention to detail are essential for success.

The RN Case Manager / Utilization Review Nurse will have the opportunity to make a meaningful impact on patient outcomes while helping improve care coordination, resource utilization, and financial performance.