The RN Case Manager - Utilization Review effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers to obtain approved certification days. They critically think for appropriateness of care provided the patients within the scope of care of the healthcare center, effectively multitasks the workday, accurately inputs computer info, and successfully accomplishes difficult tasks as assigned
- Graduate of an Registered Nursing Program, Bachelor Degree preferred
- Proficient word processing skills in a Windows environment required.
- Ability to analyze and create reports and presentations via software applications
- Familiarity with MIDAS and Meditech systems preferred.
- Bilingual (English/Spanish) preferred.
- A minimum of 3 years in acute clinical practice as an RN.
- Case management/Resource Management and discharge planning experience preferred
- Milliman (MCG) Guideline and Interqual criteria experience highly preferred.
- Negotiating skills which support the ability to interact with physicians, nursing staff, administrative staff, discharge planners, and payers.
- Excellent verbal and written communication skills, Knowledge of clinical protocol, normative data and health benefit plans, particularly coverage and limitation clauses.
- Ability to manage several projects and cases simultaneously
- Basic computer knowledge
- Ability to communicate effectively, both verbally and in writing
- Knowledge of Meditech, Midas, MCG, Interqual
- Currently licensed as RN in the State of Texas required
- CPR certification preferred
- Certification in Case Management preferred