RN - Case Manager

RN - Case Manager Profession: Nursing Specialty: Utilization Review Duration: 8 Shift: M-F Hours per Shift: 8:00 AM - 4:30 PM Experience: Minimum of 5 years of clinical nursing experience including 3 years in utilization review/case management. License: Current RN License Certifications: BSN required. Magnet-recognized Case Management certification. Must-Have: Advanced knowledge of Milliman Care Guidelines, Medicare/Medicaid, and managed care requirements. Proficiency in Cerner and EMR documentation tools. Strong assessment, organizational, and problem-solving skills. Ability to work independently and exercise sound judgment. Description:The Clinical Utilization Review Nurse II is an experienced registered nurse.This role involves prospectively and concurrently evaluating the appropriateness of inpatient and observation services.The evaluation is based on clinical documentation, evidence-based guidelines, and insurance benefits.Required clinical information must be communicated to payers according to contractual and regulatory obligations.The Level II Nurse serves as a clinical resource to physicians and providers.Education related to medical necessity, utilization review, and payer requirements is provided.Comprehensive admission and continued-stay reviews for inpatient and observation cases must be performed using facility-approved criteria and payer rules.Utilization review documentation must be accurate, timely, and audit-ready.It should clearly reflect clinical facts, criteria application, and rationale.Opportunities for alternative levels of care should be identified when criteria are not met.Concerns regarding short-stay risk, disputed status, and medical necessity must be escalated to leadership as needed.The Daily Review Tracker and other lists must be consistently maintained, updated, and reviewed in a timely manner.Data integrity should be validated, and gaps or delays should be identified, initiating corrective action as required.Concise clinical summaries for peer-to-peer discussions and payer communications must be prepared.Denial trends, avoidable days, and utilization issues within the assigned workload must be monitored and reported.Collaboration with revenue cycle on claim issues and appeals is essential.Population-specific utilization patterns should be analyzed and communicated.The promotion of evidence-based protocols, pathways, and order sets supports high-quality and cost-effective care.Participation in audits, quality improvement initiatives, and ongoing competency development is encouraged.Effective communication with physicians and co-workers in a customer service-focused manner is necessary. #J-18808-Ljbffr