RN - Case Manager

RN Utilization ReviewProvides health care services regarding admissions, case management, discharge planning, and utilization review. Reviews admissions and service requests for prospective, concurrent, and retrospective medical necessity and compliance with reimbursement policy criteria. Provides case management and consultation for complex cases. Assists departmental staff with issues related to coding, medical records/documentation, precertification, reimbursement, and claim denials and appeals. Assesses and coordinates discharge planning needs with healthcare team members. May prepare statistical analysis and utilization review reports as necessary. Oversees and coordinates compliance with federally mandated and third-party payer utilization management rules and regulations. Requires critical thinking skills, decisive judgment, and the ability to work with minimal supervision. Must be able to work in a stressful environment. Proficient and adaptable with multiple technologies simultaneously. Familiarity with payor portals and managed Medicare and Medicaid insurers preferred. Experience with Google Workspace and remote work environment preferred.