RN, Care Manager, Utilization Management (Remote, Roseville CA)
About The Position
The Adventist Health corporate headquarters, located in Roseville, California, has been established for over 40 years. In 2019, a WELL-certified campus was unveiled, offering a rejuvenating space for associates to collaborate, innovate, and connect, whether virtually or on campus. This role is crucial for ensuring patients receive high-quality care while efficiently utilizing medical resources. The Care Manager reviews patient medical records to assess the appropriateness and necessity of proposed treatments. They collaborate with healthcare providers and insurance companies to facilitate a seamless care experience, focusing on financial stewardship and denial prevention. The position aims to maximize patient outcomes and optimize resource allocation, requiring exceptional clinical knowledge, excellent communication skills, and adaptability to a fast-paced healthcare environment.
Requirements
- Associate’s Degree in nursing or equivalent combination of education/related experience
- Five years' acute hospital experience
- Two years' utilization review experience using the Optum/Inter Qual product within the last 12 months
- Registered Nurse (RN) licensure in the state of practice
Nice To Haves
- Bachelor's Degree in Nursing (BSN)
Responsibilities
- Completes clinical reviews of acute medical patients using the Optum/Inter Qual tool to determine if the patient is in the right acute setting, receiving the right acute services, during the appropriate length of stay.
- Participates in annual Optum/Inter Qual training required.
- Takes the required annual Optum/Inter Qual Interrater Reliability (IRR) test with a minimum passing score as defined in the yearly departmental goals.
- Meets weekly productivity metrics within 90 days of completing orientation and maintains on a weekly basis as defined in the yearly departmental goals.
- Meets quality audit metrics within 90 days of completing orientation and maintained on the audit cadence set within the department as defined in the yearly departmental goals.
- Completes all required departmental education assigned with timeliness and accuracy.
- Follows all departmental workflows in communication variances to the on-site care management teams when appropriate.
- Reviews and analyzes medical records to assess the necessity and appropriateness of treatments and interventions.
- Collaborates with healthcare professionals to develop and implement comprehensive patient care plans.
- Facilitates communication between the patient, healthcare team, insurance providers, and other stakeholders to ensure a coordinated and efficient care process.
- Stays up to date with the latest healthcare regulations, insurance guidelines, and evidence-based practices to ensure the delivery of optimal healthcare services.
- Performs other job-related duties as assigned.
Benefits
- Access to a WELL-certified campus designed to promote well-being and inspire best work
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
Number of Employees
5,001-10,000 employees
