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Job description
An exciting opportunity is available for an experienced RN Case Manager / Utilization Review Nurse to join a respected healthcare organization focused on quality, patient-centered care, and efficient care delivery. This role is ideal for a detail-oriented nursing professional who enjoys clinical review, problem-solving, and collaborating across the healthcare team.
The RN Case Manager / Utilization Review Nurse will play a key role in evaluating medical necessity and ensuring patients receive the appropriate level of care. This position will conduct prospective, concurrent, and post-discharge reviews using approved clinical criteria. The nurse will also evaluate admission status, monitor continued stays, and ensure documentation meets CMS, payer, and regulatory requirements.
The Utilization Review RN will work closely with physicians, case managers, physician advisors, and interdisciplinary teams to resolve documentation concerns and support accurate patient status determinations. A major focus of the role will be denial management. Responsibilities include identifying denials, preparing appeal letters, coordinating supporting documentation, and analyzing payer trends to help reduce future denials.
This RN Case Manager will also support discharge planning when needed. The nurse will help identify barriers to discharge and coordinate resources such as home health, durable medical equipment, medications, and therapy services. The role will also monitor avoidable days and extended lengths of stay while contributing to utilization reports, quality initiatives, regulatory reviews, and staff education.
Qualified candidates must hold an active Texas RN license and current CPR certification. A BSN is preferred along with case management certification. Candidates should have at least five years of experience in case management, discharge planning, and utilization review. Strong critical thinking, organization, communication, and attention to detail are essential for success.
The RN Case Manager / Utilization Review Nurse will have the opportunity to make a meaningful impact on patient outcomes while helping improve care coordination, resource utilization, and financial performance.
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Who can apply
Review the original listing for work authorization, qualifications and employer requirements.