RN Case Manager - Utilization Review

INTEGRIS Health•OK, OK

3d•Remote

About The Position

INTEGRIS Health is seeking a dedicated RN Case Manager for a remote, full-time day role in Oklahoma City, with work every other weekend. The position assesses patients’ clinical, psychological, and financial needs; coordinates appropriate levels of care and discharge planning; and supports effective utilization of hospital and community resources. The RN Case Manager collaborates with patients, families, physicians, hospital staff, and other care providers to coordinate services, improve clinical resource management, and support quality patient outcomes. The role also requires a current Oklahoma driver’s license and an acceptable driving record because it may involve operating an INTEGRIS-owned or personal vehicle.

Requirements

At least 2 years of experience in a clinical setting, such as home health, inpatient care, a physician office, or a clinic.
BLS (Basic Life Support) certification issued by the American Red Cross or American Heart Association within 30 days of hire.
Current Oklahoma Registered Nurse (RN) license or a current multistate license from a Nurse Licensure Compact (eNLC) member state.
Excellent interpersonal communication and collaboration skills.
Computer experience.
Ability to communicate effectively in English, verbally and in writing.
Current Oklahoma State driver’s license and a driving record acceptable to the company’s insurance carrier.

Nice To Haves

Experience with managed care and payer/provider requirements.
Bachelor of Science in Nursing.
Case Management Certification.

Responsibilities

Complete comprehensive assessments of patients’ clinical, psychological, and financial needs using available resources.
Recommend and coordinate timely transfers to appropriate levels of care based on clinical needs and utilization criteria.
Develop, implement, evaluate, and revise discharge plans, including referrals to health care and community organizations.
Communicate discharge plans and changes to patients, families, and appropriate health care professionals.
Assist physicians and hospital staff with appropriate resource utilization by applying utilization criteria and facilitating timely discharge planning.
Coordinate services between hospital departments to facilitate timely patient discharge.
Conduct concurrent review of patient records at admission and as indicated by the patient’s clinical condition.
Apply utilization criteria accurately to determine appropriate resource utilization.
Notify designated internal and external contacts about utilization issues that may affect patient care or reimbursement.
Facilitate patient transfers to other health care organizations in accordance with hospital policies and applicable state and federal guidelines and regulations.
Advise physicians on discharge planning, medical record documentation, and issues affecting resource utilization and reimbursement.
Integrate and manage established pathways to enhance clinical effectiveness and resource management.
Maintain knowledge of CMS, Medicare/Medicaid, managed care, and other payer regulations and benefit limits.
Educate patients, family members, and health care professionals about applicable federal health care regulations and payer requirements.
Maintain knowledge of hospital and community resources and facilitate use of the most appropriate level of care.
Identify opportunities to reduce the cost of managing patient care without affecting quality or outcomes.
Collect and record data for utilization and Quality Improvement reporting.
Work collaboratively and professionally with patients, families, physicians, hospital staff, and other individuals and agencies involved in patient care.