RN - Utilization Review / Case Management

ScionHealth

  • Lawton, OK
  • Permanent
  • Full-time
  • 6 days ago
DescriptionAt ScionHealth, we empower our caregivers to do what they do best. We value every voice by caring deeply for every patient and each other. We show courage by running toward the challenge and we lean into new ideas by embracing curiosity and question asking. Together, we create our culture by living our values in our day-to-day interactions with our patients and teammates.Job SummaryThe RN-Case Manager is responsible for assessing, planning, coordinating, and monitoring the healthcare services and resources necessary to meet the individual needs of patients. This role ensures effective case management processes that promote optimal patient outcomes, quality of care, regulatory compliance, and cost efficiency across the continuum of care.Essential Functions
  • Reviews clinical documentation and coordinates care across departments to ensure medically necessary services are provided in a timely and cost-effective manner
  • Performs discharge planning by identifying patient needs and arranging post-discharge services including home health, medical equipment, and rehabilitation
  • Collaborates with interdisciplinary team members, physicians, patients, and families to support quality care and safe transitions
  • Communicates with insurance providers and payers for authorization and continued stay approvals
  • Documents all activities, decisions, communications, and patient education in the EMR
  • Participates in performance improvement initiatives, utilization review, and data collection efforts for administrative reporting
  • Conducts 48-hour post-discharge follow-up calls as applicable
  • Advocates for the patient and serves as a liaison between healthcare providers, patients, families, and community resources
  • Assists with readmission assessments and care coordination strategies
  • Keeps current with Medicare/Medicaid rules, CMS guidelines, and payer requirements
Knowledge/Skills/Abilities/Expectations
  • Advanced understanding of case management principles, patient advocacy, and discharge planning
  • Strong critical thinking, time management, and problem-solving skills
  • Excellent interpersonal and communication abilities
  • Familiarity with utilization management, payer authorization processes, and EMR systems
  • Capacity to work independently and collaboratively in a high-pressure environment
  • Commitment to maintaining patient confidentiality and upholding ethical standards
  • Ability to prioritize multiple responsibilities and adjust to changes in work schedule or patient needs
QualificationsEducation
  • Associate Degree in Nursing, required
  • Bachelor of Science in Nursing (BSN), preferred
Licenses/Certifications
  • Current and valid Registered Nurse license in the state of practice or Compact State RN license
  • Basic Life Support (BLS) - required within time frame specified in facility policy
  • Accredited Case Manager (ACM) Certification as required by facility policy
Experience
  • Minimum of 1-2 years of clinical experience in an acute hospital, clinic, home health, hospice, or mental health facility, required
  • Previous case management experience preferred

ScionHealth