RN Case Manager - Utilization Review

Complete comprehensive assessments of patients’ clinical, psychological, and financial needs Recommend and coordinate timely transfers to appropriate levels of care Develop, implement, evaluate, and revise discharge plans, including referrals Communicate discharge care plans and changes to patients, families, and healthcare professionals Assist physicians and hospital staff with resource utilization and timely discharge planning Coordinate services between hospital departments to facilitate patient discharge Conduct concurrent reviews of patient records Apply utilization criteria to determine appropriate resource utilization Notify internal and external contacts of utilization issues affecting patient care or reimbursement Facilitate patient transfers in accordance with hospital policies and state and federal guidelines Advise physicians on discharge planning, documentation, resource utilization, and reimbursement Manage established care pathways to enhance clinical effectiveness and resource management Maintain knowledge of CMS, Medicare, Medicaid, managed care, payer regulations, and benefit limits Educate patients, families, and healthcare professionals regarding payer regulations Identify appropriate hospital and community resources and levels of care Identify cost-reduction opportunities without compromising quality or outcomes Collect and record data for utilization and Quality Improvement reporting Collaborate with patients, families, physicians, hospital staff, and care agencies Requirements 2 years of experience in a clinical setting, such as home health, inpatient, physician office, or clinic Current BLS certification issued by the American Red Cross or American Heart Association within 30 days of hire Current Registered Nurse licensure in Oklahoma or a current multistate license from an eNLC member state Excellent interpersonal communication and collaboration skills Computer experience Effective verbal and written communication in English Current Oklahoma State Driver’s License Driving record acceptable to the employer’s insurance carrier Experience with managed care and payer/provider requirements preferred Bachelor of Science in Nursing preferred Case Management Certification preferred Core Competencies Demonstrates expertise in patient assessment, discharge planning, and resource utilization while ensuring compliance with CMS, Medicare, and Medicaid regulations. Strong ability to communicate effectively with patients, families, and healthcare professionals to facilitate timely and efficient care transitions. Highest-signal resume keywords Patient Assessment Discharge Planning Resource Utilization BLS Certification Registered Nurse Licensure ATS Optimization Keywords Hard Skills Clinical Assessment Discharge Planning Utilization Review Data Collection Quality Improvement Reporting Soft Skills Interpersonal Communication Collaboration Effective Verbal Communication Written Communication Certifications & Qualifications BLS Certification Case Management Certification Industry Keywords CMS Regulations Medicare Medicaid Managed Care Payer Regulations Tools & Technologies Computer Experience #J-18808-Ljbffr