About the position

The RN Case Manager/Utilization Review is responsible for performing prospective, concurrent, and post‑discharge utilization reviews to ensure appropriate patient status, medical necessity, and compliance with hospital policy, payer requirements, and applicable local, state and federal regulations, including Centers for Medicare & Medicaid Services (CMS) guidelines. The role supports accurate admission status determinations, active denial management, and collaboration with physicians, case managers, and interdisciplinary team members to promote efficient patient progression through the episode of care. This position also assists with discharge planning activities and contributes to quarterly and annual utilization review reporting and performance improvement initiatives.

Responsibilities

• Conduct comprehensive medical record reviews using specific criteria and guidelines as approved and/or established by medical staff, CMS, and other state and federal agencies while ensuring physician and nurse documentation meets set standards.
• Perform prospective (pre‑admission and pre‑operative), concurrent, and post‑discharge utilization reviews to verify medical necessity and appropriate level of care throughout the episode of care using the hospital-approved criteria software.
• Screen and determine appropriate admission status (inpatient, observation, outpatient, or outpatient in a bed) based on clinical documentation, hospital‑approved medical-necessity guidelines, and payer requirements.
• Facilitate appropriate admission status determinations based on clinical documentation and payer requirements.
• Review clinical documentation for accuracy, completeness, and compliance with regulatory and payer standards.
• Collaborate with physicians and nursing staff to ensure timely, accurate orders and documentation supporting medical necessity.
• Communicate with physicians when cases do not meet admission or continued stay criteria and assist with resolution.
• Submit timely admission, continued stay, and discharge notification and appropriate clinicals to insurance companies as required.
• Complete admission status changes as needed in the hospital computer system.
• Identify, track, and manage utilization review denials related to admission status, level of care, length of stay, and medical necessity.
• Draft, write, and submit denial appeal letters using clinical judgment, medical record review, applicable payer, CMS, and regulatory guidelines to support medical necessity determinations.
• Collaborate with physicians, case managers, physician advisors, and leadership to obtain supporting clinical documentation, physician statements, and peer‑to‑peer review input for appeals to support denial resolution.
• Monitor denial outcomes, appeal success rates, and payer trends; analyze root causes and provide feedback, education, and recommendations to reduce future denials.
• Maintain accurate documentation of denials and appeals in accordance with hospital policy and regulatory requirements.
• When needed, collaborate with the Case Management team to support timely and safe discharge planning.
• Serve as the patient advocates and enhances collaborative relationships with the healthcare team, physicians, patients, and families to maximize the patient’s and family’s ability to make informed healthcare decisions.
• When needed, assist in identifying and addressing barriers to discharge, including durable medical equipment (DME), home health services, medications, and therapy need.
• Reinforce patient and family education to promote successful transitions of care.
• When needed, transmit Continuity of Care Documents to appropriate post‑acute providers to ensure follow‑up care.
• Monitor, track, and analyze avoidable days and extended lengths of stay; identify contributing factors related to utilization, payer processes, discharge barriers, and system delays, and collaborate with Case Management, physicians, and interdisciplinary teams to support timely resolution.
• Assist the Case Management Manager and Quality Director with data collection and analysis for quarterly and annual utilization review reports.
• Participate in regulatory audits, surveys, and internal reviews related to utilization management.
• Investigate and report adverse occurrences and trends related to utilization, discharge planning, or resource management.
• Provide staff education related to utilization review processes, medical necessity, and resource utilization.
• Must demonstrate high attention to detail, the ability to multi-task, prioritize, and have strong critical thinking skills to address issues that arise unexpectedly.
• Must encompass the skill to follow through with tasks and situations while providing clear communication to others throughout the process.
• Maintain a high standard of professionalism and ethical conduct in accordance with hospital policies and the Methodist Hospital for Surgery Code of Conduct.
• Support and facilitate initiatives enhancing patient outcomes, patient satisfaction, and regulatory compliance.
• Communicate effectively, professionally, accurately, and timely with all staff and patients.
• Demonstrates the spirit of philosophy, mission, and values of the hospital through words and actions and implements them into departmental processes, programs, and the working environment
• Perform other duties as assigned or required.

Requirements

• Active RN license in Texas
• current CPR certification
• At least five years of experience with Case Management, Discharge Planning, and Utilization Review

Nice-to-haves

• Bachelor of Science in Nursing preferred.
• Case Management Certification(s) preferred.