RN Case Manager: Utilization Review & Care Coordination

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

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.