OU Health
RN Case Manager - Utilization Review - Days
OU Health, Edmond, Oklahoma, United States, 73034
Position Title:RN Case Manager - Utilization Review - Days
Department:Case Management
Job Description:New to OU Health? Ask your recruiter about our competitive total rewards package including a $10,000 sign-on bonus!
Location:
University of Oklahoma Medical Center
Shift Available : Full-Time (40 Hourly/Weekly) 8 hours 7:30-4:30p or 8a-5p Monday-Friday with some Weekend Rotation typically every 4-6 weeks.
General Description:
Conducts Timely Medical necessity review for patients using nationally accepted criteria to determine appropriateness of admission and level of care. Communicates with insurance companies and members of the care team as needed using critical thinking skills, clinical expertise, and sound medical judgement
Essential Responsibilities:Conduct timely medical necessity reviews for all patients using medical coverage guideline (MCG) criteria to determine appropriateness of admission and level of care.Present all cases that do not meet Clinical criteria, questionable admissions, and prolonged lengths of stays to the Medical Director for determination.Frequent correspondence with payers to ensure clinical review is sent to payers in a timely manner.Ensure that the health care services administered to the patients in the highest quality yet at the same time cost-efficient and in compliance with the current regulationsComplete continuous review and audit of the patients treatment record to prevent unnecessary procedures, ineffective treatment, and unnecessary extensive hospital staysUse critical thinking skills, clinical expertise, and judgement along with established medical criteria to provide a recommendation of level of care to physicianFollow HIPPA guidelines for patient privacyReview charts to ensure documentation and medical necessity meet Medicare regulationsReview insurance denials and attempt to get them overturnedCommunicate with members of the Healthcare teamCreate reports out of system as neededUtilize various computer applicationsAttend meetings online or in person as required.General Responsibilities:
Perform other duties as assigned.Minimum Requirements:
Education:
Graduate from an accredited school school of nursing required. Bachelor of Science (or higher) in Nursing Board Approved Program preferred.
Experience:
Three (3) years clinical nursing experience in an acute care facility. Experience with utilization review or case management preferred. MCG experience preferred.
Licensure/Certifications/Registrations Required:
Current RN License issued by the Oklahoma State Board of Nursing, or a current multistate Compact RN License (eNLC). Case management certification preferred.
Knowledge, Skills & Abilities:
Knowledge of nursing practices and proceduresStrong clinical assessment skills and critical thinking skillsRequires knowledge of third party payer issues concerning reimbursement and regulatory perimeters.Must be proficient with basic computer skills. (Microsoft Office products)Knowledge of insurance terminology and Medicare guidelinesExcellent typing skillsAbility to work independently, manage time and prioritize patient needsAbility to work under minimal supervision in a remote environmentAble to work some weekends and holidaysAble to adapt to frequent changes in directionExcellent interpersonal and communications skills with nursing staff, physicians, nurse practitioners and other health workersAbility to meet deadlines and manage multiple priorities, and effectively adapt and respond to complex, fast-paced, rapidly growing, and results-oriented environmentsAble to work in a dynamic, fast-paced team environment and to promote team concepts
#CB
Current OU Health Employees - Please click
HERE
to login.OU Health is an equal opportunity employer. We offer a comprehensive benefits package, including PTO, 401(k), medical and dental plans, and many more. We know that a total benefits and compensation package, designed to meet your specific needs both inside and outside of the work environment, create peace of mind for you and your family.
Department:Case Management
Job Description:New to OU Health? Ask your recruiter about our competitive total rewards package including a $10,000 sign-on bonus!
Location:
University of Oklahoma Medical Center
Shift Available : Full-Time (40 Hourly/Weekly) 8 hours 7:30-4:30p or 8a-5p Monday-Friday with some Weekend Rotation typically every 4-6 weeks.
General Description:
Conducts Timely Medical necessity review for patients using nationally accepted criteria to determine appropriateness of admission and level of care. Communicates with insurance companies and members of the care team as needed using critical thinking skills, clinical expertise, and sound medical judgement
Essential Responsibilities:Conduct timely medical necessity reviews for all patients using medical coverage guideline (MCG) criteria to determine appropriateness of admission and level of care.Present all cases that do not meet Clinical criteria, questionable admissions, and prolonged lengths of stays to the Medical Director for determination.Frequent correspondence with payers to ensure clinical review is sent to payers in a timely manner.Ensure that the health care services administered to the patients in the highest quality yet at the same time cost-efficient and in compliance with the current regulationsComplete continuous review and audit of the patients treatment record to prevent unnecessary procedures, ineffective treatment, and unnecessary extensive hospital staysUse critical thinking skills, clinical expertise, and judgement along with established medical criteria to provide a recommendation of level of care to physicianFollow HIPPA guidelines for patient privacyReview charts to ensure documentation and medical necessity meet Medicare regulationsReview insurance denials and attempt to get them overturnedCommunicate with members of the Healthcare teamCreate reports out of system as neededUtilize various computer applicationsAttend meetings online or in person as required.General Responsibilities:
Perform other duties as assigned.Minimum Requirements:
Education:
Graduate from an accredited school school of nursing required. Bachelor of Science (or higher) in Nursing Board Approved Program preferred.
Experience:
Three (3) years clinical nursing experience in an acute care facility. Experience with utilization review or case management preferred. MCG experience preferred.
Licensure/Certifications/Registrations Required:
Current RN License issued by the Oklahoma State Board of Nursing, or a current multistate Compact RN License (eNLC). Case management certification preferred.
Knowledge, Skills & Abilities:
Knowledge of nursing practices and proceduresStrong clinical assessment skills and critical thinking skillsRequires knowledge of third party payer issues concerning reimbursement and regulatory perimeters.Must be proficient with basic computer skills. (Microsoft Office products)Knowledge of insurance terminology and Medicare guidelinesExcellent typing skillsAbility to work independently, manage time and prioritize patient needsAbility to work under minimal supervision in a remote environmentAble to work some weekends and holidaysAble to adapt to frequent changes in directionExcellent interpersonal and communications skills with nursing staff, physicians, nurse practitioners and other health workersAbility to meet deadlines and manage multiple priorities, and effectively adapt and respond to complex, fast-paced, rapidly growing, and results-oriented environmentsAble to work in a dynamic, fast-paced team environment and to promote team concepts
#CB
Current OU Health Employees - Please click
HERE
to login.OU Health is an equal opportunity employer. We offer a comprehensive benefits package, including PTO, 401(k), medical and dental plans, and many more. We know that a total benefits and compensation package, designed to meet your specific needs both inside and outside of the work environment, create peace of mind for you and your family.