Regional Care Manager

Wellpath•Lemoyne, PA

11d

About The Position

Now is your moment to make a difference in the lives of the underserved. If there is one unifying characteristic of everyone on our team, it is the deep desire to make a difference by helping society's most vulnerable and often overlooked individuals. Every day we have the distinct honor and responsibility to show up with non-judgmental compassion to provide hope and healing to those who need it most. For those whose calling it is to serve others, now is your moment to join our mission to provide quality care to every patient with compassion, collaboration, and innovation, to live our mantra to “Always Do The Right Thing!”, and to collectively do our part to heal the world, one patient at a time. The Regional Care Manager (RCM) works collaboratively with the Utilization Medical Director, Regional Medical Directors, and Site Leadership to oversee utilization review, daily care management, and care coordination for multiple sites and states. This role is responsible for analyzing and supporting off-site medical care during an inmate's stay in the acute care setting. The RCM plays a crucial role in ensuring quality care for inmates and promoting efficient and effective use of resources across the correctional healthcare system.

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 specific skill in MS word, Excel, and Power Point.
Current Nursing Licensure

Nice To Haves

RN preferred.
Case Management Certification preferred

Responsibilities

Conduct clinical review and apply InterQual Criteria for off-site observation, outpatient, and acute care as per department procedures.
Review and document concurrent clinical information in the ERMA Care Management System, and comply with tracking and following the Medical Review procedure, including claims holds.
Review and pre-certify referrals for outpatient physician visits, office procedures, surgical procedures, imaging, and specialty services, including urgent, scheduled, and routine cases.
Coordinate care with Regional Medical Directors, Site Medical Directors, and Operations personnel as needed, while routinely reviewing utilization entries for accuracy.
Collaborate with Care Management team to develop core competencies, best practices, policies, and procedures, including regulatory compliance, while using the Customer Liability Matrix for billing information.