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Utilization Management RN – Case Management
Location: Longview, TX
Status: Full-Time
Shift: Days, Monday-Friday, 8:00a-5:00p
Overview
A respected acute-care hospital in Longview, TX is seeking an experienced Registered Nurse to join its Case Management team as a Utilization Management Nurse. In this role you will use your clinical judgment to make sure patients receive the right level of care in the right setting, partnering with physicians, physician advisors, and payors to support medical necessity and prevent denials. It’s a great fit for an acute-care RN ready to step away from the bedside into a Monday-Friday day schedule.
What You’ll Do
- Perform pre-admission, concurrent, and retrospective utilization reviews using InterQual, MCG, and the CMS Inpatient Only List
- Assess medical necessity, level of care, and patient status (inpatient vs. observation) and recommend appropriate changes
- Review the surgery schedule to confirm correct status and required authorizations
- Monitor observation patients for discharge readiness or conversion to inpatient
- Communicate clinical information to commercial and government payors to obtain certification for services
- Refer cases to the physician advisor for secondary reviews, peer-to-peer reviews, and denial avoidance
- Partner with physicians and the care team to strengthen documentation supporting level of care
- Apply regulatory requirements such as IMM and Condition Code 44 and stay current on payor and Joint Commission guidelines
- Participate in multidisciplinary care progression rounds and document per regulatory and department standards
- Precept new team members and support special projects as needed
What You Bring
- Graduate of an accredited school of nursing
- Active RN license in Texas or a compact state
- 2+ years of clinical experience including at least 1 year in acute care
- Familiarity with InterQual and/or MCG criteria preferred
- Working knowledge of utilization management, case management, discharge planning, and managed care reimbursement
- Strong critical thinking, communication, and negotiation skills; comfortable working independently in a fast-paced environment
- Case Management certification preferred
- BLS preferred
Schedule & Compensation
- Full-time, Monday-Friday, 8:00a-5:00p
- Occasional overtime, call, or travel to nearby facilities may be requested
About i4 Search Group
i4 Search Group is a healthcare recruiting firm partnering with leading hospitals and health systems nationwide. We are representing this role and will guide you through every step of the process – reach out today to learn more.
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