Case Manager/Utilization Review RN

Case Manager/Utilization Review Registered Nurse (RN)

Department: Case Management/Utilization Review

Reports To: Chief Nursing Officer

Position Summary

The Case Manager/Utilization Review Registered Nurse (RN) coordinates case management and utilization review (UR) functions across all patient care areas, including MedSurg, Geriatric Psychiatry, Emergency Services, and Swing Bed, and assists in any area as needed. The role ensures appropriate, cost-effective, high-quality care while maintaining compliance with hospital policies, payer requirements, and regulatory standards. The RN collaborates with physicians, nursing staff, ancillary departments, and payers to facilitate optimal outcomes. This role also assists with quality documentation, monthly reporting, and quality initiatives that support the hospital’s performance improvement goals.

Essential Duties and Responsibilities

• Conducts concurrent and retrospective utilization reviews to validate medical necessity, level of care, and compliance with payer guidelines.

• Performs comprehensive case management functions: assessment, planning, coordination, monitoring, and patient advocacy across the continuum.

• Partners with providers and the interdisciplinary team to support timely, safe, and appropriate discharge planning.

• Communicates with payers to obtain initial and continued-stay authorizations; documents payer interactions and determinations.

• Identifies potential denials; escalates and collaborates with providers and leadership for resolution and prevention.

• Supports Swing Bed operations including admission review, continued-stay oversight, and compliance with CMS CAH requirements.

• Assists with or completes quality documentation and reviews; supports monthly reporting for case management, UR, and quality.

• Collaborates with leadership and staff to help achieve organizational quality goals and regulatory requirements.

• Participates in performance improvement activities related to case management, utilization review, quality, and compliance.

• Maintains accurate, timely documentation in the medical record and hospital systems; preserves confidentiality.

• Educates patients and families on coverage, discharge plans, post-acute options, and available resources.

• Works a flexible schedule, including alternating weekend coverage for routine admission review/on-call; flexes weekday hours accordingly in coordination with leadership.

• Serves as a resource to clinical staff regarding case management, UR processes, and payer requirements.

• Adheres to hospital policies, professional ethics, and applicable regulations.

Qualifications

• Registered Nurse (RN) license in Arkansas or compact eligibility (required).

• Minimum three years of hospital case management and/or utilization review experience (required).

• Working knowledge of CMS and CAH regulations, payer rules, medical necessity criteria, and discharge planning workflows.

• Experience with quality reporting/documentation or performance improvement (preferred).

• Strong communication, negotiation, and interpersonal skills; proven critical thinking and problem solving.

• Ability to manage multiple priorities in a fast-paced environment; organized and detail-oriented.

Certifications

• Basic Life Support (BLS) (required).

• Case management certification (CCM, ACM, or similar) (preferred).

Working Conditions

• Hospital-based role with routine payer communication (phone and electronic).

• Rotating weekend coverage for routine admissions/on-call as scheduled.

• Weekday schedule flexing may be required to balance weekend coverage and ensure continuity of services.

• Must be able to lift, push, pull, and carry up to 50 pounds occasionally and assist with patient mobility as needed.

• Must be able to stand, walk, bend, stoop, and sit for extended periods.

Qualifications

• Registered Nurse (RN) license in Arkansas or compact eligibility (required).

• Minimum three years of hospital case management and/or utilization review experience (required).

• Working knowledge of CMS and CAH regulations, payer rules, medical necessity criteria, and discharge planning workflows.

• Experience with quality reporting/documentation or performance improvement (preferred).

• Strong communication, negotiation, and interpersonal skills; proven critical thinking and problem solving.

• Ability to manage multiple priorities in a fast-paced environment; organized and detail-oriented.

Certifications

• Basic Life Support (BLS) (required).

• Case management certification (CCM, ACM, or similar) (preferred).

The Case Manager/Utilization Review Registered Nurse (RN) coordinates case management and utilization review (UR) functions across all patient care areas, including MedSurg, Geriatric Psychiatry, Emergency Services, and Swing Bed, and assists in any area as needed. The role ensures appropriate, cost‑effective, high‑quality care while maintaining compliance with hospital policies, payer requirements, and regulatory standards. The RN collaborates with physicians, nursing staff, ancillary departments, and payers to facilitate optimal outcomes. This role also assists with quality documentation, monthly reporting, and quality initiatives that support the hospital’s performance improvement goals.