Regional Care Manager (Midwest or Eastern Region)

Wellpath • Franklin, TN

3h

About The Position

The Regional Care Manager (RCM) is responsible for utilization review, care coordination, and daily care management across multiple sites and states. This role ensures accurate and timely clinical reviews of off-site care, including observation, outpatient, and acute services. The RCM handles pre-certification for urgent, scheduled, and routine procedures while applying InterQual criteria and maintaining compliance with departmental policies. They collaborate with medical directors, site leadership, and care management teams to enhance best practices and regulatory compliance. This position requires frequent communication with clients, providers, and site personnel, as well as travel for meetings, training, and support as needed.

Requirements

• Graduation from an accredited School of Nursing or Care Management Certification
• Previous utilization review and/or case management and pre-certification experience
• Knowledge of InterQual evidence-based guideline tools
• 3+ years of hands on clinical experience
• Computer proficiency with MS Word, Excel, and PowerPoint
• Current Nursing Licensure

Nice To Haves

• RN preferred
• Case Management Certification preferred

Responsibilities

• Conduct clinical reviews of off-site observation, outpatient, and acute care using InterQual criteria.
• Review and document concurrent clinical information in ERMA Care Management and Track Via systems, ensuring compliance with claims and medical review procedures.
• Manage pre-certification referrals for urgent, scheduled, and routine services including physician visits, procedures, imaging, and specialty care.
• Coordinate care with medical directors, site staff, and operations to ensure accuracy in utilization data and billing processes.
• Collaborate with the Care Management team to develop best practices, core competencies, and regulatory compliance procedures.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees