Registered Nurse Case Manager - PRN

The Case Manager / Utilization Review (UR) Coordinator at Serenity Oaks IRF manages the continuum of care for rehabilitation inpatients, coordinating insurance authorizations, concurrent utilization review, and discharge planning to ensure medically necessary, cost-effective care throughout the IRF stay. This role serves as the primary liaison with payors, managed care organizations, and Medicare Administrative Contractors (MACs) for coverage determinations, length-of-stay management, and appeals. The Case Manager works collaboratively with the IDT, attending physicians, and social work to optimize patient outcomes and facilitate timely, appropriate transitions of care.

2. ESSENTIAL FUNCTIONS & RESPONSIBILITIES

• Coordinate insurance pre-authorization and concurrent review for all inpatient admissions; communicate coverage determinations to the IDT.

• Monitor clinical documentation for medical necessity in alignment with Medicare Part A, Medicaid, and commercial payor requirements.

• Conduct daily utilization review rounds; review patient status with attending physician and IDT for continued stay justification.

• Manage IRF length of stay in alignment with CMS benchmarks and payor-specific LOS requirements.

• Facilitate timely, appropriate discharge planning in collaboration with the interdisciplinary team.

• Coordinate post-discharge referrals including home health, SNF placement, outpatient therapy, and durable medical equipment.

• Prepare and submit clinical documentation for insurance appeals, peer-to-peer reviews, and external case reviews.

• Serve as primary payor contact for case management inquiries and concurrent review communications.

• Ensure compliance with the CMS Two-Midnight Rule and IRF medical necessity criteria for all ongoing stays.

• Participate in weekly IDT meetings; provide case management status updates on each patient.

• Maintain accurate and timely case management documentation in the EHR.

• Track and analyze LOS, readmission, and discharge disposition data; report to administration.

• Collaborate with the billing team on documentation gaps, coding queries, and revenue cycle issues.

• Participate in CIHQ program evaluation and utilization management quality improvement activities.

3. EDUCATION & EXPERIENCE REQUIREMENTS

• Required: Associate degree in nursing, health sciences, or related field; BSN or bachelor's in health administration preferred.

• Preferred: BSN or BSW with two (2) or more years of case management experience.

• Required: Minimum two (2) years of utilization review, case management, or discharge planning experience in an acute care or IRF setting.

• Preferred: IRF or post-acute case management experience with Medicare Part A and managed care populations.

4. LICENSURE, CERTIFICATION & REGISTRATION REQUIREMENTS

• Preferred: Current RN license issued by the Louisiana State Board of Nursing (LSBN) or social work license from LSBSWE.

• Preferred: Certified Case Manager (CCM) from the Commission for Case Manager Certification (CCMC).

• Preferred: Accredited Case Manager (ACM) from the American Case Management Association (ACMA).

• Required: Current BLS/CPR certification if clinically credentialed.

• Required: Any held Louisiana clinical license must be verified through the applicable board prior to employment.

5. KNOWLEDGE, SKILLS & ABILITIES

• Knowledge of Medicare Part A IRF-PPS coverage criteria, 60% Rule, and LOS management.

• Understanding of managed care authorization processes and insurance appeal procedures.

• Knowledge of post-acute care options including SNF, home health, LTACH, and outpatient therapy.

• Proficiency with utilization review criteria (InterQual, Milliman, or equivalent).

• Strong communication skills for payor, IDT, physician, and patient/family interactions.

• Knowledge of IRF discharge planning requirements under CMS CoPs.

• Proficiency with EHR documentation and case management software.

• Analytical skills for tracking and interpreting LOS and utilization data.

• Familiarity with CIHQ standards related to case management and care coordination.

• Commitment to ethical, patient-centered care coordination practice.

Experience:

• Inpatient Case Management: 1 year (Preferred)

License/Certification:

• RN License (Preferred)

Work Location: In person