Utilization Review Case Management Rn Jobs in Allen, TX

GENERAL SUMMARY OF DUTIES:

We are seeking an experienced and dynamic Registered Nurse (RN) to lead our Case Management team, with a strong focus on Utilization Review. The Manager of Case Management will oversee the daily operations of the case management department, ensuring efficient utilization management, compliance with regulatory requirements, and optimal patient care outcomes. This role requires a strategic thinker who can collaborate across departments and with medical staff to improve care coordination and reduce unnecessary hospital stays.

REQUIREMENTS:

• RN license required with BSN 

• Certification in Case Management (CCM) or Utilization Review (ACM) strongly preferred

• Familiarity with EPIC and MCG Indicia preferred  

• Minimum of 3 years of previous case management experience is required in a hospital setting
• Understands the importance of teamwork when achieving desired results
• Understands basic CMS guidelines and has experience working with payor specific medical policies and reimbursement methodologies
• Understands how to use InterQual or Milliman to determine the appropriate level of care
• Understands basic coding principles and chargemaster operations
• Ability to be assertive with persuasive communication skills; action oriented
• Ability to be organized and efficient with time
• Ability to be compassionate to people and their situations to work with them in a positive way that will help them make positive forward strides
• Critical thinking skills, decisive judgment, and the ability to work with minimal supervision while meeting firm deadlines
• Communication skills necessary to be a good listener and speak in an understandable way
• Previous supervisory experience preferred

ESSENTIAL FUNCTIONS:

Leadership and Team Management

• • Lead, mentor, and manage the small case management team
  • Develop, maintain, and implement policies and procedures to improve departmental efficiency and compliance with regulatory agencies
  • Conduct regular performance evaluations and provide professional development opportunities

Utilization Review and Compliance

• • Oversee the utilization review process to ensure appropriate use of healthcare services
  • Ensure compliance with Medicare and commercial payer requirements
  • Analyze data to identify trends in utilization and recommend process improvements

Care Coordination and Case Management

• • Facilitate seamless transitions of care across the continuum (e.g., inpatient, outpatient, home health)
  • Collaborate with physicians, nurses, and other healthcare professionals to develop and implement patient-centered care
  • Facilitate the discharge planning process for our patient population

Data Analysis and Reporting

• • Monitor and report on key performance indicators (KPIs), including readmission rates, length of stay (LOS), and denial management
  • Monitor and maintain regulatory forms (e.g., IMM, MOON)

Regulatory Compliance and Accreditation

• • Ensure department adherence to DNV standards, CMS Condition of Participation, and other accrediting bodies
  • Stay updated on changes in healthcare regulations and payer policies

Interdisciplinary Collaboration

• • Serve as a liaison between case management, clinical staff, and administrative leadership
  • Participate in hospital committees and quality improvement initiatives

 PHYSICAL DEMANDS:

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• While performing the duties of this job the employee is frequently required to sit, converse, and listen; use hands to touch, handle, or feel objects, tools or controls; and to reach with hands and arms. Specific vision abilities required by this job include close vision and the ability to adjust focus.
• The employee must be able to lift and/or carry 15 pounds on an occasional basis and be able to push/pull 5 pounds on an occasional basis.
• The employee must be able to stand and/or walk at least five hours per day

 WORK ENVIRONMENT:

• The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.