RN, Care Manager, Utilization Management (Remote)
About The Position
The RN, Care Manager, Utilization Management plays a critical role in ensuring patients receive high-quality care while medical resources are used efficiently. The role reviews patient medical records to assess the necessity and appropriateness of proposed treatments and interventions, and collaborates with healthcare providers and insurance companies to support coordinated care, financial stewardship, and denial prevention. The position focuses on maximizing patient outcomes and optimizing resource allocation in a fast-paced, changing healthcare environment. The position completes clinical reviews of acute medical patients using the Optum/Inter Qual tool to evaluate whether patients are in the appropriate acute setting, receiving appropriate acute services, and staying for an appropriate length of time. It also supports comprehensive patient care planning, communication among patients and stakeholders, compliance with departmental workflows and metrics, and adherence to current healthcare regulations, insurance guidelines, and evidence-based practices. The role is remote.
Requirements
- Associate’s Degree in nursing or an equivalent combination of education and related experience.
- Five years of acute hospital experience.
- Two years of 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).
- Experience in critical care areas.
Responsibilities
- Complete clinical reviews of acute medical patients using the Optum/Inter Qual tool to assess setting, services, and length of stay.
- Participate in annual Optum/Inter Qual training and take the required annual Interrater Reliability test, meeting the departmental passing score.
- Meet weekly productivity metrics within 90 days of completing orientation and maintain them as defined by yearly departmental goals.
- Meet quality audit metrics within 90 days of completing orientation and maintain them according to the department's audit cadence.
- Complete assigned departmental education accurately and on time.
- Follow departmental workflows, including communicating variances to on-site care management teams when appropriate.
- Review and analyze medical records to assess the necessity and appropriateness of treatments and interventions.
- Collaborate with healthcare professionals to develop and implement comprehensive patient care plans.
- Facilitate communication among patients, the healthcare team, insurance providers, and other stakeholders to support coordinated and efficient care.
- Stay current with healthcare regulations, insurance guidelines, and evidence-based practices.
- Perform other job-related duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
