RN Case Manager: Care Coordination & Reimbursement

Kent Regency; Warwick (RI); On-site; USD 100,000 - 110,000; Full time

Benefits offered by this job

Tuition discounts

Employee Assistance Program

401K

Health, Dental, Vision insurance

Life insurance

Job summary

Kent Regency in Warwick, RI is seeking an Internal Case Manager (RN) to drive quality patient outcomes through assessment, utilization management, and discharge planning. You will collaborate with physicians, social workers, and rehab staff to align care with payor requirements and contract terms.

Applicants should have an active RN license, at least five years of clinical nursing experience, and familiarity with InterQual or Milliman criteria.

Qualifications

• Must be a graduate of an approved school of nursing with a license as a Registered Nurse or equivalent professional license.
• Bachelor’s degree in nursing preferred; CCM or related certifications are also preferred.
• Five years of recent clinical nursing experience required; prior experience in utilization review, case management or discharge planning required.
• Prior experience using evidence-based clinical decision support criteria (e.g., InterQual, Milliman).
• Advanced knowledge of third-party reimbursement, insurance coverage and contract requirements.
• Experience in rehabilitation nursing, acute care and/or the insurance field is preferred.
• Two years’ full-time experience in case management, which includes service to short/long-term facility-based residents, is preferred.

Responsibilities

• Lead assessment, utilization management, advocacy, and discharge planning to ensure appropriate care and minimize financial risk.
• Bridge care plans with payor requirements and contract terms.
• Serve as the clinical reimbursement resource for physicians, nurse practitioners, social workers, MDS coordinators, and rehab directors.
• Monitor cases for service over/under-utilization and assist with clinical appeals and notices of non-coverage.
• Identify risk factors and barriers to discharge; coordinate transitions with network providers and local staff.

Skills

Nursing license

Case management

Utilization review

Discharge planning

Interdisciplinary collaboration

Contract knowledge

Rehabilitation nursing

Education

Bachelor's degree in nursing

CCM certification

Tools

InterQual

Milliman

Job description

Kent Regency in Warwick, RI is seeking an Internal Case Manager (RN) to drive quality patient outcomes through assessment, utilization management, and discharge planning. You will collaborate with physicians, social workers, and rehab staff to align care with payor requirements and contract terms.

Applicants should have an active RN license, at least five years of clinical nursing experience, and familiarity with InterQual or Milliman criteria.