Job Title
Registered Nurse - Utilization Review & Case Management
Job Summary
Join our dedicated team as a Registered Nurse specializing in Utilization Review and Case Management at a prominent healthcare facility in Sitka, Alaska. This vital role focuses on optimizing patient care progression and ensuring efficient resource utilization for admitted patients.
The Case Manager RN will be instrumental in reviewing patient records, evaluating progress, and monitoring the necessity and appropriateness of hospitalization, length of stay, and quality of care. This includes providing utilization management functions for both direct admissions and Purchased/Referred Care Services beneficiaries.
You will collaborate closely with physicians, clinical care teams, and leadership to develop personalized treatment plans, ensure adherence to Utilization Management (UM), Case Management (CM), and Discharge Planning (DCP) plans, and facilitate timely, appropriate patient discharges while adhering to regulatory and payer requirements.
Key Responsibilities
- Manage patient progression of care, promote evidence-based protocols, and ensure appropriateness of interventions to expedite care delivery.
- Direct patient care services to ensure timely and appropriate patient discharge.
- Perform continuing review of patient hospitalizations to monitor medical necessity, appropriateness of care, length of stay, and quality of services.
- Conduct utilization management and review functions for patients admitted to the facility and those referred to other facilities via Purchased/Referred Care Services.
- Obtain and review necessary medical reports and treatment plans as requested by regulatory agencies or payers.
- Review and validate physician orders, report patient progress, and document unusual occurrences.
- Collaborate with leadership, clinical care teams, and physicians to ensure healthcare services are appropriate and cost-effective, adhering to UM/CM/DCP plans.
- Assess new hospital admissions to determine patient conditions and needs for personalized treatment plan development.
- Provide patients and/or their families with information regarding healthcare benefits.
- Participate in interdisciplinary collaboration with professional staff and review patient records.
- Ensure maintenance of the Utilization Review Plan in collaboration with the Utilization Review Medical Director or designated provider.
- Facilitate educational programs and advise physicians and other departments on regulations affecting UM/CM/DCP.
- Direct the coordination of patient care departments, ensuring treatment plans meet patient needs and comply with hospital, regulatory, and payer criteria.
- Ensure documentation supports UM functions and communicate with payers within required timeframes.
- Review information, communicate results to claims adjusters, and enter appropriate billing information.
- Prepare information for notification letters to providers, staff, and patients.
- Receive and process requests for appeal of denials and respond to complaints per UM review guidelines.
- Maintain utilization review and appeal logs.
- Support clinical improvement initiatives by providing quality review.
- Perform tumor registry functions as required.
Required Qualifications
- Bachelor’s Degree in Nursing (BSN).
- High School Diploma or equivalent.
- 8 years of clinical care or nursing experience, with at least 3 years specifically in chart review, risk management, or related quality service.
- Current Flu vaccine required.
Preferred Qualifications
- Case Management certification by a recognized certifying organization (e.g., NCQA, CCMC).
Skills & Competencies
- Clinical Skills:
- Proficiency in conducting and reviewing medical records for medical necessity, level of care determination, and public/private insurance reimbursement.
- Basic knowledge of ICD-9 and CPT coding.
- Understanding of regulations set forth by The Centers for Medicare & Medicaid Services (CMS).
- Proficient in medical terminology, anatomy, physiology, and concepts of disease.
- Ability to provide effective nursing care and assess patient situations to take effective courses of action.
- Soft Skills:
- Strong written and oral communication skills.
- Strong organizational skills.
- Ability to communicate and collaborate effectively with providers, staff, and patients.
Shift Details
- Shift Type: AM
- Shift Duration: 8 hours
- Days per Week: 5 days
- Contract Length: 13 weeks
- Start Date: October 5, 2026
- Call Requirements: Not specified.
- Weekend Rotations: Not specified.
- Note: Start date is contingent upon successful completion of pre-employment fingerprinting and background checks, which may require a processing time of approximately 6 weeks.
Licensing Requirements
- Active Registered Nurse (RN) license in Alaska required at the time of submission.