RN Case Manager - Utilization Review

Join our team at INTEGRIS Baptist Medical Center in Oklahoma City, OK as a full-time RN Case Manager - Utilization Review on the day shift/variable schedule.

About Us

INTEGRIS Health is Oklahoma’s largest not-for-profit health system, dedicated to partnering with people to live healthier lives. With hospitals, rehabilitation centers, physician clinics, mental health facilities, and home health agencies across much of the state, INTEGRIS Health offers career growth and development opportunities.

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.
• Assists physicians and hospital staff in appropriate utilization of resources through application of utilization criteria and facilitating timely discharge planning for patients.
• 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 the most appropriate level of care to conserve patient, hospital, and payer resources.
• Identifies opportunities to reduce the 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, physicians, hospital staff, and other individuals and agencies involved in providing patient care.

Requirements

• 2 years of experience in a clinical setting (e.g., home health, inpatient, physician office, clinic).
• Current licensure as a Registered Nurse (RN) in the State of Oklahoma or current multistate license from a Nurse Licensure Compact (eNLC) member state.
• BLS (Basic Life Support) certification issued by the American Red Cross or American Heart Association within 30 days of hire.
• Excellent interpersonal communication and collaboration skills.
• Computer experience.
• Must be able to communicate effectively in English (verbal/written).
• Must have a current Oklahoma State Driver’s License and a driving record acceptable to our insurance carrier (required to operate an INTEGRIS-owned or personal vehicle).

Preferred Qualifications

• Experience with managed care and payer/provider requirements.
• Bachelor’s of Science in Nursing (BSN).
• Case Management Certification.

Benefits

• Front-loaded PTO.
• Medical benefits through the extensive INTEGRIS Health network.
• Financial assistance for continued education.
• 24/7 mental health support.