Utilization Management Nurse II - Case Management

Responsibilities

• Moves patient status appropriately based on clinical information and treatment plans.
• Utilizes approved screening criteria (InterQual/MCG/CMS Inpatient List) to assess medical necessity and level of care.
• Collaborates with interdisciplinary teams to facilitate joint decision-making regarding patient status and outcomes.
• Ensures compliance with regulatory requirements and CHRISTUS CORE values.
• Communicates with payors and vendors to obtain approved certification for services.
• Reviews surgery schedules and ensures necessary authorizations are obtained.
• Monitors patients in observation status for discharge or conversion to inpatient status.
• Identifies and resolves clinical appropriateness recommendations, coverage issues, and potential payor denials.
• Maintains consistent communication with payors to coordinate certification of hospital services.
• Evaluates care administered by the interdisciplinary health care team and advocates for standards of practice.
• Analyzes assessment data to identify potential problems and formulate goals/outcomes.

Requirements

• Graduate of an accredited School of Nursing OR at least five years of demonstrated success in the Utilization Management Nurse I role at CHRISTUS Health.
• Two or more years of clinical experience with at least one year in the acute care setting OR at least five years of demonstrated success in the Utilization Management Nurse I role at CHRISTUS Health.
• RN License in state of employment or compact required. LPN or LVN license accepted for associates with 5+ years of demonstrated success and experience in the Utilization Management Nurse I role at CHRISTUS Health.
• Certification in Case Management preferred.
• BLS preferred.