Case Manager Utilization Review RN

APPLICATION DEADLINE: 04/20/2025

Job Summary:

The RN Case Manager/Utilization Reviewer is responsible for hospital case management/utilization review, and discharge planning to assure that patients progress through the continuum of care, while ensuring compliance with local, state and federal regulatory agencies and The Joint Commission.

Hours:

- 1.0 FTE - 40 Hours Per Week

• Day Shift

The RN Case Manager/Utilization Reviewer facilitates coordination of medical care and discharge planning processes with interdisciplinary collaboration with service organizations, agencies and healthcare facilities, as well as facilitating the procurement of durable medical equipment.

• The Case Manager conducts medical record reviews using specific indicators and criteria as approved by medical staff, The Joint Commission, CMS, and other state and federal agencies while ensuring physician and nurse documentation meet set standards.
• Understand utilization review/case management rules and guidelines to ensure compliance.
• The Case Manager educates members of the healthcare team on case management and managed care concepts and serves as the patient advocate and enhances a collaborative relationship with the healthcare team, physicians, patients and families to maximize the patient’s and family’s ability to make informed healthcare decisions.
• This position reinforces/facilitates patient/family education, to enhance a positive discharge transition.
• Investigates and reports adverse occurrences, and performs staff education related to resource utilization, discharge planning and psychosocial aspects of healthcare delivery.
• The RN Case Manager will assist PI Data RN with data gathering as needed to support regulatory reporting
• Works collaboratively with Social Workers to support meeting psycho-social needs of patients and families or care givers.
• The RN Case Manager will perform other duties as assigned.

Professional Responsibilities

• Assist the Inpatient (Second Floor) Manager and Clinical Operations Coordinator with Inpatient PI/chart audits, medication audits, antibiotic audits, unit-specific tracking tools
• Model professional behavior in accordance with the Second Floor Code of Conduct
• Support and facilitate initiatives enhancing patient satisfaction
• Communicate effectively, professionally, accurately, and timely with all staff and patients
• Hold staff accountable to OLSH and Second Floor Codes of Conduct and standards of professional behavior

Qualifications, Knowledge & Ability:

• Demonstrates eligibility for employment in the U.S.
• Current licensure as RN, in the State of Wisconsin required, BSN preferred. Previous experience working in a hospital environment is required
• Experience with Case Management and Discharge Planning required
• Five (5) years of experience in Utilization Review required
• BLS certification is required upon hire
• Ability to relate and work effectively with others
• Demonstrates skills in verbal, written and electronic English communications for safe and effective patient care and to meet documentation standards
• Willingness to participate in goal-setting and educational activities for own professional advancement
• Is aware of professional standards and performs in accordance with them

Benefits:

• Comprehensive health, dental, and vision insurance
• Health Savings Account with an employer contribution
• Company paid life insurance
• Free meals
• PTO
• 401(k) retirement plan with 4% company match
• Tuition reimbursement
• Wellness reimbursement