Offer summary

Qualifications:

Graduate from an accredited school of nursing required, with a Bachelor of Science in Nursing preferred., Three years of clinical nursing experience in an acute care facility is required, with experience in utilization review or case management preferred., Current RN License issued by the Oklahoma State Board of Nursing or a multistate Compact RN License is required., Strong clinical assessment, critical thinking skills, and proficiency in basic computer skills are essential. .

Key responsibilities:

Conduct timely medical necessity reviews for patients to determine appropriateness of admission and level of care.

Communicate with insurance companies and healthcare team members regarding patient care and insurance denials.

Complete continuous reviews and audits of patient treatment records to ensure compliance with regulations and prevent unnecessary procedures.

Create reports and attend meetings as required, while following HIPAA guidelines for patient privacy.

Job description

Position Title:

RN Case Manager - Utilization Review

Department:

Case Management

Job Description:

General Description: Conducts Timely Medical necessity review for patients using nationally accepted criteria to determine appropriateness of admission and level of care. Communicates with insurance companies and members of the care team as needed using critical thinking skills, clinical expertise, and sound medical judgement

Essential Responsibilities:

Conduct timely medical necessity reviews for all patients using medical coverage guideline (MCG) criteria to determine appropriateness of admission and level of care.
Present all cases that do not meet Clinical criteria, questionable admissions, and prolonged lengths of stays to the Medical Director for determination.
Frequent correspondence with payers to ensure clinical review is sent to payers in a timely manner.
Ensure that the health care services administered to the patients in the highest quality yet at the same time cost-efficient and in compliance with the current regulations
Complete continuous review and audit of the patients treatment record to prevent unnecessary procedures, ineffective treatment, and unnecessary extensive hospital stays
Use critical thinking skills, clinical expertise, and judgement along with established medical criteria to provide a recommendation of level of care to physician
Follow HIPPA guidelines for patient privacy
Review charts to ensure documentation and medical necessity meet Medicare regulations
Review insurance denials and attempt to get them overturned
Communicate with members of the Healthcare team
Create reports out of system as needed
Utilize various computer applications
Attend meetings online or in person as required.

General Responsibilities:

Perform other duties as assigned.

Minimum Requirements:

Education: Graduate from an accredited school school of nursing required. Bachelor of Science (or higher) in Nursing Board Approved Program preferred.

Experience: Three (3) years clinical nursing experience in an acute care facility. Experience with utilization review or case management preferred. MCG experience preferred.

Licensure/Certifications/Registrations Required: Current RN License issued by the Oklahoma State Board of Nursing, or a current multistate Compact RN License (eNLC). Case management certification preferred.

Knowledge, Skills & Abilities:

Knowledge of nursing practices and procedures
Strong clinical assessment skills and critical thinking skills
Requires knowledge of third party payer issues concerning reimbursement and regulatory perimeters.
Must be proficient with basic computer skills. (Microsoft Office products)
Knowledge of insurance terminology and Medicare guidelines
Excellent typing skills
Ability to work independently, manage time and prioritize patient needs
Ability to work under minimal supervision in a remote environment
Able to work some weekends and holidays
Able to adapt to frequent changes in direction
Excellent interpersonal and communications skills with nursing staff, physicians, nurse practitioners and other health workers
Ability to meet deadlines and manage multiple priorities, and effectively adapt and respond to complex, fast-paced, rapidly growing, and results-oriented environments
Able to work in a dynamic, fast-paced team environment and to promote team concepts