Case Manager, RN – Utilization Review

🔥 15 hours ago

🌪️ Kansas, Oklahoma, +2 more states – Remote

🌪️ Kansas – Remote 🌪️ Oklahoma – Remote 🏰 Missouri – Remote 🤠 Texas – Remote

⏱ Part Time

🟡 Mid-level

🟠 Senior

👔 Manager

🦅 H1B Visa Sponsor

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👻 Ghost score 10%

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OU Health

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

OU Health is a comprehensive healthcare provider offering a wide range of medical services including pediatric care, cancer care, diabetes care, emergency care, and specialized services for adults and children. Located in Oklahoma, OU Health operates multiple facilities such as the Oklahoma Children's Hospital and the Stephenson Cancer Center. Known for its advanced scientific research and quality care, the organization prides itself on being recognized for excellence in areas like pediatric cardiology and heart surgery. As part of its commitment to medical excellence, OU Health also focuses on medical education and research, helping to train the next generation of healthcare professionals.

📋 Description

• Conduct comprehensive assessments of patients' health status, medical history, and ongoing care needs using evidence-based criteria tools • Coordinate with interdisciplinary healthcare teams, payors, patients, and families to ensure appropriate status and financial reimbursement • Educate patients and families regarding healthcare stays and appropriate status • Facilitate communication among patients, families, healthcare providers, and payors • Evaluate evidence-based criteria tools and payor platforms; identify issues and escalate them to leadership • Evaluate healthcare utilization patterns and identify opportunities to improve efficiency and cost-effectiveness • Ensure timely authorization of services and coverage for hospital care and treatment • Monitor patient and healthcare system financial outcomes and processes • Participate in quality improvement initiatives and interdisciplinary care conferences • Ensure compliance with federal, state, and local regulations and accreditation requirements • Implement strategies to minimize readmissions and prevent financial complications • Precept newly hired Nursing Utilization Review care managers • Participate in secondary case review, policy maintenance, quality/performance improvement, and assigned workgroups • Maintain continuing education, process competencies, and participation in quality audit reviews • Maintain a HIPAA-compliant work environment while working from home • Lead Care Management team meetings and interdisciplinary rounds • Complete assigned Leadership Academy classes • Perform other duties as assigned

🎯 Requirements

• Candidates must reside and work full-time in Arkansas, Kansas, Missouri, Oklahoma, or Texas before their first day of employment • PRN positions require a minimum of 2 shifts/month • Bachelor's Degree in Nursing required • At least 3 years of Nursing experience required; Care Management experience preferred • Current Registered Nurse License issued by the Oklahoma State Board of Nursing, or a current multistate compact Registered Nurse (eNLC) • Expertise in regulatory requirements regarding Utilization Review care management • Strong communication, interpersonal, and leadership skills • Excellent organizational skills and attention to detail • Strong assessment, critical thinking, and problem-solving skills • Knowledge of healthcare regulations, including CMS guidelines and Payor Contractual agreements • Understanding of utilization management principles and Nursing care management responsibilities • HIPAA-compliant work-from-home practices to safeguard PHI • Proficiency in electronic health records (EHR) and care management software • Must provide secure Internet and Cellular phone services

🏖️ Benefits

• Paid time off (PTO) • 401(k) • Medical plans • Dental plans • Comprehensive benefits and compensation package • Secure internet and cellular phone services required for work from home