RN Case Manager - Utilization Review

Responsibilities

• Completes a comprehensive assessment of patients clinical, psychological and financial needs utilizing all available resources.
• Recommends and coordinates timely transfers to appropriate levels of care as indicated by clinical needs and utilization criteria.
• Develops, implements, evaluates and revises, as necessary, a plan for discharge, including referrals to other health care and community organizations based on needs assessment.
• Communicates discharge care plan, and any changes in the plan to patient, family and all appropriate healthcare professionals.
• Affords assistance to physicians and hospital staff in appropriate utilization of resources through application of utilization criteria and facilitating timely discharge planning for patients.
• Collaborates and coordinates services between hospital departments to facilitate timely patient discharge.
• Conducts concurrent review of patient records on admission to the hospital and as determined by the patient's clinical condition.
• Applies utilization criteria accurately in order to determine appropriate utilization of resources.
• Notifies designated internal and external contacts of utilization issues that may affect patient care and/or reimbursement.
• Facilitates patient transfers to other health care organizations in accordance with hospital policies and all-applicable state and federal guidelines and regulations.
• Acts as a resource/advisor to physicians regarding discharge planning, medical record documentation, and all issues that may affect resource utilization and reimbursement.
• Integrates and manages established pathways, where available, to enhance clinical effectiveness and clinical resource management.
• Maintains knowledge and understanding of CMS regulations, Medicare/Medicaid, managed care and other payer regulations and benefit limits.
• Acts as a resource and provides education for patients, their family members and all health care professionals regarding HCFA regulations, Medicare, Medicaid, managed care and other payers.
• Develops and maintains knowledge and understanding of hospital and community resources, and facilitates use of most appropriate level of care to conserve patient, hospital, and payer resources.
• Identifies opportunities to reduce cost of managing patient care without impacting quality or outcomes.
• Participates in collecting and recording data for utilization and Quality Improvement reporting.
• Works collaboratively and professionally with patients, family members, and physicians, hospital staff and other individuals and agencies involved in providing patient care.

Qualifications

• EXPERIENCE: 2 years experience in a clinical settings (e.g. home health, inpatient, physician office, clinic)
• LICENSE/CERTIFICATIONS: BLS (Basic Life Support) Issued by American Red Cross or American Heart Association within 30 days of hire, RN (Registered Nurse) Current licensure as a Registered Nurse (RN) in the State of Oklahoma or current multistate license from a Nurse Licensure Compact (eNLC) member state
• SKILLS: Excellent interpersonal communication and collaboration skills, Computer experience
• Must be able to communicate effectively in English (verbal/written).
• This job requires the incumbents to operate a INTEGRIS-owned vehicle OR personal vehicle (non INTEGRIS-owned) and therefore must have a current Oklahoma State Drivers License as well as a driving record which is acceptable to our insurance carrier.
• PREFERRED QUALIFICATIONS: Experience with managed care and payer/provider requirements, Education: Bachelor's of Science in Nursing, LICENSE/CERTIFICATIONS: Case Management Certification