Care Manager

LabMinds Staffing & Recruiting • Sitka, AR

4d

About The Position

The Utilization Management / Case Management Registered Nurse manages patient progression of care, promotes evidence-based protocols, ensures the appropriateness of clinical interventions, and expedites care delivery for admitted patients. This position oversees discharge planning, evaluates medical necessity and length of stay, and collaborates with multidisciplinary teams to deliver cost-effective, high-quality care.

Requirements

• Active Alaska RN license required at time of submittal.
• Minimum 8 years of clinical nursing experience, with at least 3 years in chart review, risk management, or related quality service.
• Proof of flu vaccine required.
• Bachelor’s Degree in Nursing (BSN).
• Active, unrestricted Registered Nurse (RN) license in the State of Alaska at time of submission.
• 8 years of clinical care or nursing experience required, with a minimum of 3 years dedicated to chart review, risk management, or quality service.
• Understanding of medical necessity criteria, level of care reviews, public/private insurance reimbursement, CMS regulations, basic CPT/ICD coding, medical terminology, anatomy, and disease processes.
• Strong clinical assessment, critical thinking, organizational, and case tracking skills.
• Excellent written and verbal communication skills; ability to collaborate effectively with providers, interdisciplinary staff, patients, payers, and claims adjusters.

Nice To Haves

• Case Management certification by a recognized body (e.g., NCQA, CCMC) preferred.
• Case Management certification (NCQA, CCMC, or equivalent) preferred.

Responsibilities

• Conduct ongoing reviews of patient records to evaluate medical necessity, appropriateness of hospitalization, length of stay, and quality of care.
• Perform utilization management (UM) and review functions for beneficiary patients admitted to external facilities.
• Review new admissions to assess clinical conditions and assist in developing personalized care plans.
• Obtain and review medical reports and treatment plans requested by payers and regulatory agencies.
• Maintain the Utilization Review Plan in collaboration with UM staff and the Medical Director (or designated provider).
• Direct patient care services to ensure timely and appropriate patient discharge planning (UM/CM/DCP).
• Collaborates with leadership, physicians, and multidisciplinary care teams to ensure healthcare services are appropriate, cost-effective, and aligned with UM/CM/DCP plans.
• Educate patients and their families regarding healthcare benefits and care progression.
• Facilitate educational programs to advise physicians and hospital departments on regulations affecting UM/CM/DCP.
• Ensure clinical documentation supports UM functions and communicate with payers within mandatory timeframes.
• Receive and process denial appeal requests, respond to complaints per UM guidelines, and maintain utilization review and appeal logs.
• Communicate review results to claims adjusters, enter billing information, and prepare provider/patient notification letters.
• Perform tumor registry functions and support clinical quality improvement initiatives.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level