Care Management Utilization Review RN
OUMC Utilization Review
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**This position may be filled as a Level 1, 2, or 3 depending on specific education, experience, and license requirements.**
Remote Eligibility: Candidates must reside and work full-time in AR, KS, MO, OK, or TX before their first day of employment .
***Please be aware that you will need a private HIPAA-compliant space to work in due to the nature of the work***
The RN Care Manager Utilization Review I is an entry level position that collaborates with health care providers to ensure patients receive appropriate care while adhering to healthcare regulations. This work is performed through evaluation of medical necessity, collaboration with insurance companies, patients, patient families and providers and securing payor authorization for hospital stays.
Essential Responsibilities
Responsibilities listed in this section are core to the position. Inability to perform these responsibilities with or without an accommodation may result in disqualification from the position.
Conducts comprehensive assessments of patients' health status, medical history, and ongoing care needs utilizing evidence-based criteria tools.
Coordinates with the interdisciplinary healthcare team, Payors, patients and families to ensure appropriate status and financial reimbursement.
Provides education to patients and their families regarding their healthcare stay and appropriate status in compliance with mandated regulatory and financial expectations.
Coordinates and facilitates communication between patients, families, healthcare providers, and Payor sources to optimize appropriate patient and healthcare system financial reimbursement outcomes.
Evaluates patient clinical information, utilizes Evidence based criteria tool and collaborates with Payors as required.
Evaluates healthcare utilization patterns and identifies opportunities for improving efficiency and cost-effectiveness based on Payor contracts and Healthcare Mandated regulatory guidelines.
Advocates for appropriate status to meet patient and system needs while adhering to regulatory guidelines and reimbursement criteria.
Collaborates with insurance providers, Interdisciplinary teams, and other stakeholders to ensure timely authorization of services and coverage for patient hospital care and treatment.
Monitors and evaluates patient and healthcare system financial outcomes and processes to identify areas for improvement.
Participates in quality improvement initiatives and interdisciplinary care conferences to promote evidence-based practices and enhance patient safety and satisfaction.
Ensures compliance with federal, state, and local regulations, as well as accreditation requirements related to Nursing care management and patient continuum of care.
Implements approved strategies to minimize readmissions, prevent financial complications, and optimizes appropriate financial reimbursement processes.
Maintains a HIPPA compliant work environment to protect Patient Protected Health Information while working from home. Must provide secure Internet and Cellular phone services.
Maintains continuing Education with approved Evidence based criteria tool and Departmental Process Competencies and participates in Quality Audit review findings.
General Responsibilities
Performs other duties as assigned.
Minimum Qualifications (level 1)
Education: Associate's Degree in Nursing required.
Experience: 0-3 years of RN experience required, experience in Care Management preferred.
License/Certification/Registration: Current Registered Nurse License (RN License issued by the Oklahoma State Board of Nursing, or a current multistate compact Registered Nurse (eNLC).
Minimum Qualifications (level 2)
Education: Bachelor's Degree in Nursing required.
Experience: At least 3 years of Care Management experience required.
License/Certification/Registration: Current Registered Nurse License (RN License issued by the Oklahoma State Board of Nursing, or a current multistate compact Registered Nurse (eNLC).
Minimum Qualifications (level 3)
Education: Bachelor's Degree in Nursing required.
Experience: 5 or more years of Care Management experience required.
License/Certification/Registration: Current Registered Nurse License (RN License issued by the Oklahoma State Board of Nursing, or a current multistate compact Registered Nurse (eNLC).
Knowledge/Skills/Abilities Required
Demonstrates expertise in regulatory requirements regarding the Utilization Nursing care management discipline.
Strong communication, interpersonal, and leadership skills.
Detailed- oriented with excellent organizational skills.
Commitment to fostering a culture of continuous learning, quality improvement, and patient-centered care.
Strong assessment, critical thinking, and problem-solving skills
Strong knowledge of healthcare regulations, including CMS guidelines and Payor Contractual agreements
Show clear understanding of utilization management principles and integrate these with Nursing care management responsibilities.
Serve as liaison between patients, families, Payors and healthcare providers.
Demonstrates HIPPA compliance in a Work from home environment to safeguard PHI.
Proficiency in utilizing electronic health records (EHR) and care management software
Strong assessment, critical thinking, and problem-solving skills.
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