Overview The RN Case Manager is responsible for comprehensive coordination of care and service of individual patients and/or patient populations, promoting effective utilization of resources, and leading the multidisciplinary team to achieve patient and physician satisfaction and optimal outcomes. Must be able to work with all disciplines to meet patient needs from admission through discharge. Under the general supervision of the Director of Case Management, develops, coordinates, and performs daily activities to provide utilization review services. Utilizes current trends and developments in utilization review using federal, state, and other regulations for guidance. This role establishes priorities in data collection, analysis, and trending of data to demonstrate and improve quality of care, adheres to accrediting body, Federal, and State regulations, maintains patient confidentiality, and supports the hospital mission, values, and behavioral standards. Always works as a team member within the facility and performs other duties as assigned.
Essential Functions / Responsibilities Provides case management services to patients according to policy and procedure.
Ability to take direction from others and follow through concisely to promote efficiency.
Ability to set priorities.
Acts to protect and advance the patient’s best interest.
Reviews surgery schedules for appropriate admission status.
Maintains knowledge of billing, payor contracts, agreements and reimbursement issues.
Performs medical reviews for medical necessity, appropriateness of care, level of care, and quality of care for hospitalized patients.
Coordinates and conducts prospective, initial, concurrent, and retrospective medical record reviews.
Makes utilization decisions based on established criteria.
Collaborates and communicates with case managers to ensure appropriate and timely discharge planning consistent with the patient’s continued need for acute care. Faxes clinical notes to insurance companies as needed.
Good communication skills and the ability to effectively share information in a timely manner.
Able to interpret and communicate policies and procedures. Ability to comprehend and interpret complex clinical subject matter related to the department.
Demonstrates knowledge, skills, and abilities to perform the duties outlined in this job description and continually demonstrates competency in performing the job duties.
Accountability Reports to: Director of Case Management
Supervises: None
Qualifications Current Licensure with the Oklahoma State Board of Nursing
BS in Nursing or related health field preferred but not required
Minimum of three years hospital-based nursing practice; preferred experience in utilization/case management
BLS for Healthcare Providers required within 30 days of hire
Required Physical Demands Strength (Lift, Carry, Push, Pull): Light
Standing/Walking: Constantly; activity exists 2/3 or more of the time
Keyboard/Dexterity: Occasionally; activity exists up to 1/3 of the time
Talking (must be able to effectively communicate verbally): Yes
Seeing: Yes
Hearing: Yes
Color Acuity: No
Environmental Conditions Level: High
High exposure to hazardous risks including potential for exposure to infections and communicable diseases, blood and body fluids, electrical equipment and chemicals. Must follow standard precautions. May be required to work weekends or flex schedules. Travel may be required. Exposed to weather conditions during travel.
What We Offer Medical, dental, vision, and prescription coverage
Life and AD&D coverage
Availability of short- and long-term disability
Flexible financial benefits including FSAs, HSAs, and Daycare FSA
401(k) and access to retirement planning
Employee Assistance Program (EAP)
Paid holidays and vacation