About The Position
Our NEW Pediatric Behavioral Health Center is scheduled to open in December 2026. Candidates applying for this position should expect a start date after September 1, 2026. All applicants must be 21 years of age or older and provide two professional references as part of the hiring process. Registered Nurse positions are available at levels I, II, or III, depending on experience and education. New to OU Health? Ask your recruiter about our competitive total rewards package including up to a $10,000 sign-on bonus! The RN Care Manager Utilization Review collaborates with health care providers to ensure patients receive appropriate care while adhering to healthcare regulations. This work is performed through evaluation of medical necessity, collaboration with insurance companies, patients, patient families and providers and securing payor authorization for hospital stays.
Requirements
- All applicants must be 21 years of age or older
- provide two professional references as part of the hiring process
- Current Registered Nurse License (RN License issued by the Oklahoma State Board of Nursing, or a current multistate compact Registered Nurse (eNLC)).
- Demonstrates expertise in regulatory requirements regarding the Utilization Nursing care management discipline.
- Strong communication, interpersonal, and leadership skills.
- Detailed- oriented with excellent organizational skills.
- Commitment to fostering a culture of continuous learning, quality improvement, and patient-centered care.
- Strong assessment, critical thinking, and problem-solving skills
- Strong knowledge of healthcare regulations, including CMS guidelines and Payor Contractual agreements
- Show clear understanding of utilization management principles and integrate these with Nursing care management responsibilities.
- Serve as liaison between patients, families, Payors and healthcare providers.
- Demonstrates HIPPA compliance in a Work from home environment to safeguard PHI.
- Proficiency in utilizing electronic health records (EHR) and care management software
- Strong assessment, critical thinking, and problem-solving skills.
Nice To Haves
- experience in Care Management preferred.
Responsibilities
- Conducts comprehensive assessments of patients' health status, medical history, and ongoing care needs utilizing evidence-based criteria tools.
- Coordinates with the interdisciplinary healthcare team, Payors, patients and families to ensure appropriate status and financial reimbursement.
- Provides education to patients and their families regarding their healthcare stay and appropriate status in compliance with mandated regulatory and financial expectations.
- Coordinates and facilitates communication between patients, families, healthcare providers, and Payor sources to optimize appropriate patient and healthcare system financial reimbursement outcomes.
- Evaluates patient clinical information, utilizes Evidence based criteria tool and collaborates with Payors as required.
- Evaluates healthcare utilization patterns and identifies opportunities for improving efficiency and cost-effectiveness based on Payor contracts and Healthcare Mandated regulatory guidelines.
- Advocates for appropriate status to meet patient and system needs while adhering to regulatory guidelines and reimbursement criteria.
- Collaborates with insurance providers, Interdisciplinary teams, and other stakeholders to ensure timely authorization of services and coverage for patient hospital care and treatment.
- Monitors and evaluates patient and healthcare system financial outcomes and processes to identify areas for improvement.
- Participates in quality improvement initiatives and interdisciplinary care conferences to promote evidence-based practices and enhance patient safety and satisfaction.
- Ensures compliance with federal, state, and local regulations, as well as accreditation requirements related to Nursing care management and patient continuum of care.
- Implements approved strategies to minimize readmissions, prevent financial complications, and optimizes appropriate financial reimbursement processes.
- Maintains a HIPPA compliant work environment to protect Patient Protected Health Information while working from home. Must provide secure Internet and Cellular phone services.
- Maintains continuing Education with approved Evidence based criteria tool and Departmental Process Competencies and participates in Quality Audit review findings.
- Performs other duties as assigned.
Benefits
- competitive total rewards package
- PTO
- 401(k)
- medical and dental plans
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
Associate degree
