Case Manager, RN - Utilization Review - PRN

Position Title:

Case Manager, RN - Utilization Review - PRN

Department:

OUMC Utilization Review

Job Description:

Ask your recruiter about our new market-leading rates!

Remote Eligibility: Candidates must reside and work full-time in AR, KS, MO, OK, or TX before their first day of employment. Please do not apply if you reside outside these 5 states and will not relocate to one of the approved states listed.

SHIFT: PRN

**PRN POSITIONS REQUIRE A MINIMUM OF 2 SHIFTS/MONTH**

The Utilization Review RN CM is a competent professional who excels in evaluating the medical necessity and appropriateness of healthcare services and treatments. They ensure patients receive appropriate care, working closely with insurance companies, patients, and interdisciplinary providers to secure authorizations for hospital stays or treatments. Utilizing clinical knowledge and evidence-based tools, the RN CM reviews and interprets medical records accurately, managing payor denials while maintaining patient satisfaction. With strong communication skills and advanced problem-solving abilities, using technology to safeguard HIPAA Protected Health Information.

Essential Responsibilities

Responsibilities listed in this section are core to the position. Inability to perform these responsibilities with or without an accommodation may result in disqualification from the position.

• Conduct comprehensive assessments of patients' health status, medical history, and ongoing care needs utilizing Evidence based criteria tool.
• Coordinates with the Interdisciplinary healthcare team, Payors, patients and families to ensure appropriate status and Financial reimbursement.
• Provides education to patients and their families regarding their healthcare stay and appropriate status in compliance with mandated regulatory and financial expectations.
• Coordinates and facilitates communication between patients, families, healthcare providers, and Payor sources to optimize appropriate patient and healthcare system financial reimbursement outcomes.
• Evaluates effectiveness of Evidence based criteria tool and Payor platforms identifying issues and escalates to Leadership to facilitate adjustments needed. 
• Evaluate healthcare utilization patterns and identify opportunities for improving efficiency and cost-effectiveness based on Payor contracts and Healthcare Mandated regulatory guidelines.
• Advocates for and Demonstrates use of appropriate criteria status to meet patient and system needs while adhering to regulatory guidelines and reimbursement criteria. 
• Collaborates with insurance providers, Interdisciplinary teams, and other stakeholders to ensure timely authorization of services and coverage for patient hospital care and treatment.
• Monitors and evaluates patient and healthcare system financial outcomes and processes to identify areas for improvement and escalates issues to Leadership.
• Participates in quality improvement initiatives and interdisciplinary care conferences to promote evidence-based practices and enhance patient safety and satisfaction. 
• Ensures compliance with federal, state, and local regulations, as well as accreditation requirements related to Nursing care management and patient continuum of care.  
• Implements approved strategies to minimize readmissions, prevent financial complications, and optimizes appropriate financial reimbursement processes.
• Precepts newly hired Nursing Utilization Review care managers.
• Participates in departmental activities such as secondary case review, policy maintenance, quality and/or performance improvement, and assigned workgroups.
• Maintains continuing Education with approved evidence-based criteria tool and Departments process competencies and participates in quality audit review findings.
• Maintains a HIPPA compliant work environment to protect Patient Protected Health Information while working from home. Must provide secure Internet and Cellular phone services.
• Performs other duties as needed.
• Lead Care Management team meetings and interdisciplinary rounds.
• Complete Leadership academy leadership classes as assigned.

General Responsibilities

• Performs other duties as assigned.

Minimum Qualifications

Education Requirements

• Bachelor's Degree in Nursing required.
  

Experience Requirements

• At least 3 years of Nursing experience required, with Care Management experience preferred.

License/Certification/Registration Requirements

• Current Registered Nurse License (RN License issued by the Oklahoma State Board of Nursing, or a current multistate compact Registered Nurse (eNLC)).

Knowledge/Skills/Abilities Required

• Demonstrates expertise in regulatory requirements regarding the Utilization Review care management discipline. 
• Strong communication, interpersonal, and leadership skills.
• Detailed- oriented with excellent organizational skills.
• Commitment to fostering a culture of continuous learning, quality improvement, and patient-centered care.
• Strong assessment, critical thinking, and problem-solving skills 
• Strong knowledge of healthcare regulations, including CMS guidelines and Payor Contractual agreements.
• Show clear understanding of utilization management principles and integrate these with Nursing care management responsibilities.
• Serve as liaison between patients, families, Payors and healthcare providers. 
• Demonstrates HIPPA compliance in a Work from home environment to safeguard PHI.
• Proficiency in utilizing electronic health records (EHR) and care management software
• Strong assessment, critical thinking, and problem-solving skills.

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OU Health is an equal opportunity employer. We offer a comprehensive benefits package, including PTO, 401(k), medical and dental plans, and many more. We know that a total benefits and compensation package, designed to meet your specific needs both inside and outside of the work environment, create peace of mind for you and your family.

About Us

OU Health is the state’s only comprehensive academic health system of hospitals, clinics and centers of excellence. With 11,000 employees and more than 1,300 physicians and advanced practice providers, OU Health is home to Oklahoma’s largest doctor network with a complete range of specialty care. OU Health serves Oklahoma and the region with the state’s only freestanding children’s hospital, the only National Cancer Institute-Designated OU Health Stephenson Cancer Center, Oklahoma’s flagship hospital, which serves as the state’s only Level 1 trauma center and Edmond Medical Center in the heart of the Edmond Community. Becker’s Hospital Review named University of Oklahoma Medical Center one of the 100 Great Hospitals in America for 2020. OU Health’s oncology program at OU Health Stephenson Cancer Center was named Oklahoma’s top facility for cancer care by U.S. News & World Report in its 2020-21 rankings. OU Health also was ranked by U.S. News & World Report as high performing in these specialties: Colon Surgery, COPD and Congestive Heart Failure. OU Health’s mission is to lead healthcare in patient care, education and research.

Experts in prevention, treatment and cures, our team works to improve lives through innovation in medical care, education and research, while investing in the people, technologies and facilities that will enable us to achieve our goals. We are seeking individuals who have a passion and talent for caring for others. By joining our team, you will provide quality health care to our community through the work you do every day. We provide clinical and non-clinical opportunities to further your career and we invite you to explore our available positions.

Equal employment opportunities are provided to all employees and applicants for employment without regard to race, color, religion, gender, national origin, age, disability, sexual orientation, gender identity, genetic information or protected veteran status in accordance with applicable federal laws. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, placement, promotion, termination, layoff, transfer, leaves of absence, compensation, and training. Reasonable accommodations are made to the known physical and mental limitations of qualified individuals with disabilities.