Care Management Utilization Review RN - PRN (WFH - OK, TX, AR, MO, KS)

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This position may be performed remotely from the following locations within the United States of America: Arkansas, Kansas, Missouri, Oklahoma, and Texas.

Please only apply if you live and work full-time in one of the states listed above or plan to relocate to one of these states before starting your employment with OU Health. State locations and specifics are subject to change as our hiring requirements shift.

**PRN POSITIONS REQUIRE A MINIMUM OF 24HRS A MONTH**

***Please be aware that you will need a private HIPAA-compliant space to work in due to the nature of the work***

SHIFT: PRN (As Needed) - The candidate must have open availability to provide needed coverage when employees are out on pto/leave/etc.

The Care Management Utilization Review RN is a competent professional who excels in evaluating the medical necessity and appropriateness of healthcare services and treatments. They ensure patients receive appropriate care, working closely with insurance companies, patients, and interdisciplinary providers to secure authorizations for hospital stays or treatments. Utilizing clinical knowledge and evidence-based tools, the Care Management Utilization Review RN reviews and interprets medical records accurately, managing payor denials while maintaining patient satisfaction. With strong communication skills and advanced problem-solving abilities, using technology to safeguard HIPAA Protected Health Information.

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.

• Conduct comprehensive assessments of patients' health status, medical history, and ongoing care needs utilizing Evidence based criteria tool.

• 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 effectiveness of Evidence based criteria tool and Payor platforms identifying issues and escalates to Leadership to facilitate adjustments needed.

• Evaluate healthcare utilization patterns and identify opportunities for improving efficiency and cost-effectiveness based on Payor contracts and Healthcare Mandated regulatory guidelines.

• Advocates for and Demonstrates use of appropriate criteria 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 and escalates issues to Leadership.

• 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.

• Precepts newly hired Nursing Utilization Review care managers.

• Participates in departmental activities such as secondary case review, policy maintenance, quality and/or performance improvement, and assigned workgroups.

• Maintains continuing Education with approved evidence-based criteria tool and Departments process competencies and participates in quality audit review findings.

• Maintains a HIPPA compliant work environment to protect Patient Protected Health Information while working from home. Must provide secure Internet and Cellular phone services.

• Performs other duties as needed.

• Lead Care Management team meetings and interdisciplinary rounds.

• Complete Leadership academy leadership classes as assigned.

General Responsibilities

• Performs other duties as assigned.

Minimum Qualifications

Education Requirements: Bachelor's Degree in Nursing required.

Experience Requirements: A minimum of 3 years of Nursing experience is required, with Care Management experience preferred.

License/Certification/Registration Requirements: Current Registered Nurse License (RN License issued by the Oklahoma State Board of Nursing, or a current multistate compact Registered Nurse (eNLC)).

Knowledge/Skills/AbilitiesRequired

• Demonstrates expertise in regulatory requirements regarding the Utilization Review 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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