Case Manager – Utilization Review Nurse
OU Health
full-time
Posted on:
Location Type: Remote
Location: Remote • Kansas, Montana, Oklahoma, Texas • 🇺🇸 United States
Visit company websiteJob Level
Mid-LevelSenior
About the role
- Conducts Timely Medical necessity review for patients using nationally accepted criteria
- Communicates with insurance companies and members of the care team as needed
- Present all cases that do not meet Clinical criteria to the Medical Director
- Frequent correspondence with payers to ensure clinical review is sent to payers
- Ensure that the health care services administered to the patients are of the highest quality yet cost-efficient
- Complete continuous review and audit of the patients treatment record
- Use critical thinking skills, clinical expertise, and judgement along with established medical criteria to provide a recommendation of level of care to physician
- Follow HIPPA guidelines for patient privacy
- Review charts to ensure documentation and medical necessity meet Medicare regulations
- Review insurance denials and attempt to get them overturned
- Create reports out of system as needed
- Attend meetings online or in person as required.
Requirements
- Graduate from an accredited school of nursing required
- Bachelor of Science (or higher) in Nursing Board Approved Program preferred
- Three (3) years clinical nursing experience in an acute care facility
- Experience with utilization review or case management preferred
- MCG experience preferred
- Current RN License issued by the Oklahoma State Board of Nursing, or a current multistate Compact RN License (eNLC)
- Case management certification preferred
- Knowledge of nursing practices and procedures
- Strong clinical assessment skills and critical thinking skills
- Requires knowledge of third party payer issues...
Benefits
- PTO
- 401(k)
- medical and dental plans
- comprehensive benefits package
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
medical necessity reviewutilization reviewcase managementclinical assessmentchart reviewreport creationtreatment record auditinsurance denial managementcritical thinkingnursing practices
Soft skills
communicationjudgmentinterpersonal skillsorganizational skillsattention to detail
Certifications
RN Licensecase management certification