RN Case Management Utilization Review - Care Coordination

Company: Presbyterian Healthcare Services
Location: Albuquerque
Posted on: June 27, 2025

Job Description:

Overview: The RN - Case Management - Utlization Review to provide clinically-based case management to support the delivery of effective and efficient patient care. The role integrates utilization management, care coordination, and transition planning functions. The Case Manager has the overall accountability for a designated case load and plans effectively in order to meet patients needs, manage the length of stay, and promote efficient utilization of resources. In collaboration with the interdisciplinary team, the case manager IV supports the physician in facilitating patient care with the objective of enhancing the quality of patient outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payers. Preferred candidates with Utilization Review experience in a hospital setting along with RN Case management hospital-based nursing experience. How you grow, learn and thrive matters here. Educational and career development options, including tuition and certification reimbursement, scholarship opportunities Wearable alarm badges (a wearable badge that allows nurses to quickly and discreetly call for help when safety is a concern) Shift differentials for nights and weekends Differentials for higher education, certifications and various lead roles Malpractice liability insurance Loan forgiveness through the New Mexico Higher Education Department EPIC electronic charting system Type of Opportunity: Full Time FTE: 1.000000 Exempt: No Work Schedule: Varied Days and Hours Qualifications: Preferred candidates with Utilization Review experience in a hospital setting along with RN Case management hospital-based nursing experience. RN-Case Management I: Associate Degree in Nursing Registered Nurse - State of New Mexico or Compact State Nursing License required. National Case Management certification preferred Two years clinical nursing experience in relevant clinical practice area with utilization review or case management experience preferred. RN-Case Management II: Registered Nurse with Bachelors of Science in nursing (BSN) degree or Registered Nurse with Associates degree in nursing (ADN) plus five years utilization review or case management experience required. Registered Nurse - State of New Mexico or Compact State Nursing License required National Case Management certification preferred Two years clinical nursing experience in relevant clinical practice area with utilization review or case management experience preferred. RN-Case Management III: Registered Nurse with Masters of Science in nursing (MSN) degree or Registered Nurse with Bachelors in nursing (BSN) plus five years utilization review or case management experience required. Registered Nurse - State of New Mexico or Compact State Nursing License required. National Case Management certification preferred Two years clinical nursing experience in relevant clinical practice area with utilization review or case management experience preferred. RN-Case Management IV: Registered Nurse with Masters of Science in nursing (MSN) degree plus five years utilization review or case management experience or Registered Nurse with Bachelors in nursing (BSN) plus ten years utilization review or case management experience required. Registered Nurse - State of New Mexico or Compact State Nursing License required. National Case Management certification preferred Two years clinical nursing experience in relevant clinical practice area with utilization review or case management experience preferred. Responsibilities: Interviews and assesses each patient, family or other designated person(s) within 48 hours of admission in order to obtain financial, emotional, physical, social, functional and health care needs in order to define and recommend potential discharge plans, manage patient and family expectations, identify readmission risk and target interventions to reduce risk for readmission, and identify, adjust and manage barriers to discharge. Applies approved clinical criteria to monitor appropriateness of admissions and continued stays to ensure a clear status determination. Refers cases and issues to Case Management Medical Director based on departmental standards. Demonstrates skill in communicating with physicians the necessary Documentation required to demonstrate medical necessity. Elevates to Supervisor and/or Medical Director all patients not meeting criteria after discussion with physician. Demonstrates skill in educating patient, family and interdisciplinary team regarding post-acute care options, status determination, and other care coordination services. Develops implements, coordinates, monitors and evaluates preliminary and final discharge plans with the interdisciplinary team, patient and family. Arranges and/or facilitates identified discharge needs and services of patients and ensures timely intervention to prevent delays in service and transition of care. Ensures all elements of the plan of care have been communicated to the patient/family and members of the healthcare team to assure continuity of care. Participates and facilitates care progression in daily multidisciplinary rounds and addresses target length of stay with health care providers to achieve complete delivery of services within prescribed timeframe. Monitors length of stay and takes action to mitigate overutilization and elevates to medical director as needed. Presents and actively participates in complex rounds, discharge planning huddles, process improvement teams, department specific initiatives and department meetings. Identifies patients and families with complex psychosocial issues and refers them to the Social Worker as appropriate. Demonstrates skill and success in collaboration with Social Work partner. Facilitates and leads patient/family and provider care conferences as needed. Documents results of assessments, status assignment, and interventions and discharge planning in the medical record according to departmental policies and procedures. Ensures safe care to patients adhering to policies, procedures, and standards within budgetary specifications, including time management, supply management, productivity and accuracy of practice. Promotes individual and departmental professional growth and development by meeting requirements for and facilitating continuing education, skills competency. Supports departmental based goals which contribute to the success of the organization. Serves as a mentor, preceptor, mentor and resource to less expe Benefits: Benefits We're all about well-being, starting with yours. Presbyterian employees have access to a fun, engaging and unique wellness program, including free on-site and community-based gyms, nutrition coaching and classes, mindfulness and meditation resources, wellness challenges and more. Learn more about our employee benefits. Our culture is one of knowing and respecting our patients, members, and each other. We capture this in our Promise and CARES commitments About Presbyterian Healthcare Services Presbyterian exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit healthcare system comprised of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 13,000 employees - including more than 1,200 providers and nearly 3,500 nurses. Our health plan serves more than 640,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans. AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses. Maximum Offer for this position is up to: USD $52.95/Hr. Compensation Disclaimer: The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.

Keywords: Presbyterian Healthcare Services, Albuquerque , RN Case Management Utilization Review - Care Coordination, Healthcare , Albuquerque, New Mexico