Utilization Review Case Manager (45966)

Utilization Review RN Case Manager works under general supervision with a multidisciplinary team to perform prospective, concurrent, and retrospective medical reviews, support discharge planning, ensure regulatory compliance with government payers and vendors (Admission Status, Clinical Documentation, Value-Based Purchasing), and advocate for patient care needs. Responsibilities include collaborating with clinicians to assess admission status, communicating with patients/families/providers, developing individualized care plans, monitoring plan effectiveness, coordinating referrals, and maintaining confidential patient records in line with HIPAA and regulatory standards. Requires strong communication skills, familiarity with EHR systems, ICD-10/DRG coding, and knowledge of managed care contracting. Preference given to Navajo or American Indian applicants per tribal policy.