RN Case Manager / Utilization Review

Case Manager / Utilization Review Nurse (RN)

The Case Manager / Utilization Review Nurse (RN) is responsible for coordinating patient care progression, discharge planning, and utilization review activities. This integrated role ensures appropriate levels of care, regulatory compliance, efficient resource utilization, and optimal patient outcomes.

The position combines clinical Case Management functions with Utilization Review responsibilities, including medical necessity reviews, inpatient and concurrent authorizations, concurrent reviews, denial prevention, and interdisciplinary collaboration. The Case Manager / Utilization Review Nurse serves as a liaison between patients, families, providers, payers, and post-acute resources to facilitate safe, timely, and cost-effective transitions of care while supporting hospital reimbursement integrity and compliance with Medicare, Medicaid, commercial payer, and regulatory requirements.

Case Management Responsibilities

• Perform comprehensive patient assessments to identify clinical, psychosocial, financial, and discharge planning needs.
• Coordinate patient care progression and discharge planning throughout the hospitalization.
• Identify barriers to discharge and collaborate with interdisciplinary teams to facilitate timely patient progression.
• Coordinate referrals and post-acute services, including:
• Home Health
• Long-Term Care (LTC)
• Skilled Nursing Facilities (SNF)
• Durable Medical Equipment (DME)
• Community resources and support services
• Collaborate with patients, families, providers, nursing staff, therapy services, and ancillary departments regarding discharge planning and transition needs.
• Provide patient and family education on discharge plans, available resources, and support services.
• Coordinate advance discharge planning for orthopedic surgical patients, ensuring timely referrals, equipment orders, and post-discharge services.
• Participate in interdisciplinary rounds and team meetings to discuss patient progression and discharge readiness.
• Ensure timely and accurate Case Management documentation in the electronic health record (EHR).

Utilization Review Responsibilities

• Perform concurrent and retrospective utilization reviews for patient admissions and continued stays using established medical necessity criteria (e.g., MCG, InterQual) and payer-specific guidelines.
• Determine and reassess appropriate patient status, including inpatient versus observation levels of care.
• Obtain inpatient and concurrent authorizations for services in accordance with payer requirements and established timelines.
• Obtain prior authorizations and manage authorization workflows for inpatient and outpatient services as assigned.
• Submit initial and concurrent clinical documentation to payers within required timelines.
• Communicate effectively with physicians and other providers regarding medical necessity, documentation requirements, level-of-care determinations, and alternative levels of care.
• Monitor for avoidable days, delays in care progression, and opportunities to improve patient throughput.
• Identify and proactively address potential denials and reimbursement risks.
• Assist with preparation and submission of denial appeals, including supporting clinical rationale and documentation.
• Document all utilization review activities, approvals, denials, authorizations, and payer communications accurately in the EHR.
• Monitor readmissions, avoidable days, and utilization trends to support quality improvement initiatives.
• Participate actively in Utilization Review (UR) Committee activities and related compliance initiatives.
• Provide education to providers and staff regarding medical necessity documentation and payer requirements.

Requirements

Required Qualifications

• Active, unrestricted Registered Nurse (RN) license in New Mexico or a Compact State.
• Minimum of 2–3 years of recent acute care clinical experience.
• Strong knowledge of Medicare and Medicaid regulations, commercial payer guidelines, and medical necessity criteria (MCG and/or InterQual).
• Excellent critical thinking, analytical, and problem-solving skills.
• Strong verbal and written communication skills.
• Ability to work independently while managing multiple priorities in a fast-paced environment.
• Proficiency with electronic health record systems (Cerner preferred) and related software applications.

Preferred Qualifications

• Previous Case Management and/or Utilization Review experience in an acute care setting.
• Experience with inpatient and concurrent authorization management, concurrent reviews, denial prevention, appeals, discharge planning, and care coordination.
• Critical Access Hospital (CAH) experience preferred.
• Knowledge of CMS Conditions of Participation, utilization management best practices, and payer authorization processes.

Work Environment

• Acute care hospital setting.
• Combination of patient-facing and office-based responsibilities.
• Frequent interaction with interdisciplinary clinical teams, payers, patients, and families.
• Fast-paced, collaborative environment requiring effective prioritization and workflow management.

Core Competencies

• Clinical judgment and medical necessity review
• Care coordination and discharge planning
• Regulatory compliance and payer guideline knowledge
• Communication and interdisciplinary collaboration
• Time management and organizational skills
• Problem-solving and denial prevention strategies

Physical Requirements

• Ability to sit, stand, walk, and use standard office and computer equipment for extended periods.
• Ability to review electronic medical records and documentation efficiently.
• Occasional movement throughout patient care areas and hospital departments.