Case Manager – Utilization Review Nurse

Job Description: • 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