RN Case Manager - Utilization Review - Baptist Emergency Dept

INTEGRIS Health; Oklahoma City (OK); On-site; USD 65,000 - 82,000; Full time

Benefits offered by this job

Front-loaded PTO

Medical benefits

Education assistance

24/7 mental health support

Job summary

INTEGRIS Health in Oklahoma City seeks a dedicated RN Case Manager to coordinate and monitor patient care across the continuum, aiming for optimal clinical outcomes and cost efficiency. You will assess needs, arrange transfers, discharge planning, and collaborate with physicians, hospital staff, and community resources.

The role requires 2 years of clinical experience, BLS/ RN licensure in Oklahoma (or compact), and strong communication.

Qualifications

• 2 years of clinical experience in settings such as home health, inpatient, clinic, or physician office.

Responsibilities

• Completes a comprehensive assessment of patients' clinical, psychological and financial needs using available resources.
• Coordinates timely transfers to appropriate levels of care based on clinical needs and utilization criteria.
• Develops and maintains a discharge plan, including referrals to other health care and community organizations.
• Communicates discharge care plan and changes to patient, family, and all healthcare professionals.
• Assists physicians and hospital staff in utilization of resources and discharge planning.
• Coordinates services between hospital departments to facilitate timely discharge.
• Conducts concurrent review of patient records on admission and as determined by clinical condition.
• Applies utilization criteria to determine appropriate use of resources.
• Notifies internal and external contacts of utilization issues affecting patient care or reimbursement.
• Facilitates patient transfers to other health care organizations in accordance with policies and regulations.
• Acts as a resource for discharge planning, medical records documentation and payer issues.
• Integrates pathways to enhance clinical effectiveness and resource management.
• Maintains knowledge of CMS, Medicare/Medicaid, managed care and payer regulations.
• Educates patients and families about HCFA regulations, Medicare, Medicaid, and payers.
• Keeps knowledge of hospital and community resources to optimize level of care and conserve resources.
• Identifies opportunities to reduce cost without compromising quality.

Skills

Clinical experience

BLS certification

RN licensure (OK)

English communication

Job description

Get to Know Your Team:

INTEGRIS Health, Oklahoma's largest not-for-profit health system, is seeking a dedicated caregiver to join us in our mission to partner with people to live healthier lives.

Benefits of being an INTEGRIS Health caregiver include front-loaded PTO, medical benefits through the extensive INTEGRIS Health network, financial assistance for continued education, 24/7 mental health support and more.

The Case Manager is responsible for the clinical and financial outcomes for an assigned caseload of patients as appropriate. The Case Manager facilitates patient care during the hospitalization by managing, coordinating and monitoring resource utilization to achieve optimal clinical outcomes and financial goals. The Case Manager is responsible to proactively plan, coordinate and negotiate efficient patient movement throughout the continuum of care. In general, the Case Manager functions in the role of clinician, educator, researcher, manager and advocate to serve the best interests of the system and patient. Adheres to National Patient Safety Goals as appropriate based on the level of patient contact this position requires. INTEGRIS is an Equal Opportunity/Affirmative Action Employer. All applicants will receive consideration regardless of membership in any protected status as defined by applicable state or federal law, including protected veteran or disability status.

The RN Case Manager responsibilities include, but are not limited to, the following:

• Completes a comprehensive assessment of patients clinical, psychological and financial needs utilizing all available resources.
• Recommends and coordinates timely transfers to appropriate levels of care as indicated by clinical needs and utilization criteria.
• Develops, implements, evaluates and revises, as necessary, a plan for discharge, including referrals to other health care and community organizations based on needs assessment.
• Communicates discharge care plan, and any changes in the plan to patient, family and all appropriate healthcare professionals.
• Assists physicians and hospital staff in appropriate utilization of resources through application of utilization criteria and facilitating timely discharge planning for patients.
• Coordinates services between hospital departments to facilitate timely patient discharge.
• Conducts concurrent review of patient records on admission to the hospital and as determined by the patient's clinical condition.
• Applies utilization criteria accurately in order to determine appropriate utilization of resources.
• Notifies designated internal and external contacts of utilization issues that may affect patient care and/or reimbursement.
• Facilitates patient transfers to other health care organizations in accordance with hospital policies and all-applicable state and federal guidelines and regulations.
• Acts as a resource/advisor to physicians regarding discharge planning, medical record documentation, and all issues that may affect resource utilization and reimbursement.
• Integrates and manages established pathways, where available, to enhance clinical effectiveness and clinical resource management.
• Maintains knowledge and understanding of CMS regulations, Medicare/Medicaid, managed care and other payer regulations and benefit limits.
• Acts as a resource and provides education for patients, their family members and all health care professionals regarding HCFA regulations, Medicare, Medicaid, managed care and other payers.
• Develops and maintains knowledge and understanding of hospital and community resources, and facilitates use of most appropriate level of care to conserve patient, hospital, and payer resources.
• Identifies opportunities to reduce cost of managing patient care without impacting quality or outcomes.
• Participates in collecting and recording data for utilization and Quality Improvement reporting. * Works collaboratively and professionally with patients, family members, and physicians, hospital staff and other individuals and agencies involved in providing patient care.

REQUIRED QUALIFICATIONS

EXPERIENCE:

• 2 years experience in a clinical settings (e,g. home health, inpatient, physician office, clinic)

LICENSE/CERTIFICATIONS:

• BLS (Basic Life Support) Issued by American Red Cross or American Heart Association within 30 days of hire
• RN (Registered Nurse) Current licensure as a Registered Nurse (RN) in the State of Oklahoma or current multistate license from a Nurse Licensure Compact (eNLC) member state

SKILLS:

• Excellent interpersonal communication and collaboration skills
• Computer experience
• Must be able to communicate effectively in English (verbal/written). This job requires the incumbents to operate a INTEGRIS-owned vehicle OR personal vehicle (non INTEGRIS-owned) and therefore must have