RN Case Manager – Utilization Review

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 a current Oklahoma State Drivers License as well as a driving record which is acceptable to our insurance carrier.

PREFERRED QUALIFICATIONS

EXPERIENCE:

• Experience with managed care and payer/provider requirements

EDUCATION:

• Bachelor’s of Science in Nursing

LICENSE/CERTIFICATIONS:

• Case Management Certification

INTEGRIS Health is an Equal Opportunity 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.