Description
Position Summary: The RN Case Manager is responsible for comprehensive coordination of care and service of individual patients and/or patient populations, promoting effective utilization of resources, and assuming a leadership role in the multidisciplinary team to achieve patient and physician satisfaction and optimal outcomes. Must be able to work with all disciplines to meet patient needs from admission through discharge.
Under the general supervision of the Director of Case Management, develops, coordinates, and performs daily activities to provide utilization review services. Utilizes current trends and developments in utilization review using federal, state, and other regulations for guidance. This position is responsible for establishing priorities in data collection, analysis, and trending of data for purposes of demonstrating and improving quality of care. Demonstrates knowledge and adherence to accrediting body, Federal, and State regulations. Maintains confidentiality of patient's information. Performs duties in accordance with Hospital mission, values, and behavioral standards. Always works as a team member within the entire facility. Performs other duties as assigned.
Essential Functions:

• Provides case management services to patients according to policy and procedure.
• Ability to take direction from others and follow through in a concise manner, which also promotes efficiency.
• Ability to set priorities.
• Acts to protect and advance patient's best interest.
• Reviews surgery schedules for appropriate admission status.
• Maintains knowledge of billing, payor contracts, agreements and reimbursement issues.
• Responsible for performing medical reviews for medical necessity, appropriateness of care, level of care, and quality of care for hospitalized patients.
• Coordinates and conducts prospective, initial, concurrent, and retrospective medical record reviews.
• Makes utilization decisions based on established criteria.
• Collaborates and Communicates with case managers to ensure appropriate and timely discharge planning consistent with the patient's continued need for acute care. Faxes clinical notes to insurance companies as needed.
• Good communication skills and the ability to effectively share information in a timely manner.
• Able to interpret and communicate policies and procedures. Possesses the ability to comprehend and interpret complex clinical subject matter related to the department.
• Satisfactorily demonstrates the knowledge, skills and abilities to perform the duties outlined in this job description as well as continually demonstrates competency in performing the job duties.

Accountability:

• Reports to: Director of Case Management
• Supervises: None

Required Physical Demands:

• Strength (Lift, Carry, Push, Pull): Light
• Standing/Walking: Constantly; activity exists 2/3 or more of the time
• Keyboard/Dexterity: Occasionally; activity exists up to 1/3 of the time
• Talking (Must be able to effectively communicate verbally): Yes
• Seeing: Yes
• Hearing: Yes
• Color Acuity: No

Environmental Conditions:
Level: High
High exposure to hazardous risks including potential for exposure to infections and communicable diseases, blood and body fluids, electrical equipment and chemicals. Must follow standard precautions. May be required to work weekends or flex schedules. Travel may be required. Exposed to weather conditions during travel.
Requirements
Qualifications:

• Current Licensure with the Oklahoma State Board of Nursing
• BS. in Nursing or related health field preferred but not required.
• Minimum of three years hospital based nursing practice prefer experience in utilization/case management.
• BLS for Healthcare Providers required within 30 days of hire.