Registered Nurse; RN), Case Manager

Position: Registered Nurse (RN), Case Manager
Registered Nurse (RN), Clinical Case Manager

Fulltime:
Days

Schedule:

Monday-Friday 7:30a-4:00p/8:00a-4:30p

Your experience matters

Frye Regional Medical Center is part of Lifepoint Health, a diversified healthcare delivery network with facilities coast to coast. We are driven by a profound commitment to prioritize your well-being so you can provide exceptional care to others. As a Registered Nurse (RN) joining our team, you‘re embracing a vital mission dedicated to making communities healthier ®. Join us on this meaningful journey where your skills, compassion and dedication will make a remarkable difference in the lives of those we serve.

More about our team

Accountable for the execution, adaptation and outcome of care management as prescribed in the initial Utilization Review Plan with regard to resources, appropriateness of care and adherence to a designated Geometric Length of Stay (GLOS) for each patient.

Reports to:

Director of Case Management

1. Departmental Leadership & Strategic Alignment - Assists in developing departmental goals, standards, and objectives aligned with the organization‘s strategic plan and vision.

- Creates and fosters an environment that encourages professional growth.

- Integrates evidence-based practices into operations and clinical protocols.

2. Patient Care Coordination & Quality Oversight - Assesses the quality of patient care delivered and coordinates services with patients, staff, physicians, and other departments.

- Works with interdisciplinary teams to facilitate decision-making aligned with care plans and patient/family wishes.

- Coordinates care and services within the case-managed population.

3. Financial & Payer Management - Understands payer issues and anticipates opportunities to reduce expenses and capture revenue from admission through discharge.

- Educates physicians and staff on Case Management standards and regulatory requirements (Joint Commission, OSHA, CMS, HCFA, AHCA).

- Mentors staff on Utilization Review (UR) standards and Length of Stay (LOS) topics.

4. Clinical Assessment & Care Planning - Performs patient/family assessments on admission to identify individualized care management needs.

- Collaborates with nursing staff to plan strategies for care needs requiring nursing expertise.

- Coordinates care plans and services to integrate patients into the healthcare continuum.

- Develops, reviews, and revises care pathways for specific DRGs to meet regulatory requirements and reduce LOS and readmissions.

Job Description Report REPORT GENERATED: JULY 8, 2025, 8:11 AM - Ensures timely and accurate documentation of care plans and Case Management interventions.

- Advocates for patients and families throughout the care episode.

5. Interdisciplinary Collaboration - Participates in Interdisciplinary Team Meetings.

- Maintains effective communication with all disciplines.

- Provides feedback to the healthcare team regarding patient progress and barriers to care.

- Coordinates changes to the care plan as needed.

6. Utilization Review & Documentation - Performs admission and concurrent medical record reviews.

- Documents utilization review per departmental guidelines.

- Facilitates physician documentation to reflect patient condition, comorbidities, and procedures.

- Educates patients/families on third-party payer guidelines and discharge financial implications.

- Manages denial appeals and chart audit reviews.

7. Case Management - Acts as gatekeeper for hospital admissions by initiating care in the ED.

- Encourages use of reimbursable diagnoses and interfaces with community agencies.

- Creates care plans for high-utilization patients and redirects to appropriate hospital services.

- Monitors and manages resource use to prevent extended LOS.

- Observes ED processes and ensures appropriate level-of-care placement.

- Uses EMR and MCG Criteria for utilization management and quality screening.

- Identifies and resolves delays in care and discharge planning.

- Consults with appropriate departments to expedite care.

- Applies conflict resolution skills to ensure timely issue resolution.

- Applies utilization acuity criteria and documents findings.

- Identifies at-risk populations and follows…