RN - Case Manager

RN Utilization Review

Provides 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 coding, medical records/documentation, precertification, reimbursement, and claim denials/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. Centralized acute admission utilization review across various care settings.

Minimum 2 years in acute care utilization management or equivalent License: Licensed RN (multistate or Texas RN) Certifications: BLS Must-Have: - Proficiency with InterQual/MCG and CMS regulations. - Experience with payor portals, managed Medicare and Medicaid insurers. - Proficient and adaptable in using multiple technologies simultaneously. - Remote work experience preferred.