RN, Care Manager, Utilization Management (Remote)
About The Position
The RN, Care Manager, Utilization Management reviews patient medical records to assess whether proposed treatments and services are necessary and appropriate. The role uses the Optum/InterQual tool to evaluate whether acute medical patients are in the appropriate setting, receiving appropriate acute services, and staying for an appropriate length of time. It also supports high-quality patient outcomes, effective use of medical resources, financial stewardship, and denial prevention. The position collaborates with healthcare providers, on-site care management teams, insurance providers, patients, and other stakeholders to support coordinated care and comprehensive patient care plans. The care manager follows departmental workflows, maintains required training and performance standards, and stays current with healthcare regulations, insurance guidelines, and evidence-based practices. Other job-related duties may be assigned.
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/InterQual product within the last 12 months.
- Registered Nurse (RN) licensure in the state of practice.
- Ability to complete required Optum/InterQual training and annual Interrater Reliability testing.
- Ability to meet departmental productivity and quality audit metrics.
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/InterQual tool to assess the appropriateness of the acute setting, services, and length of stay.
- Participate in required annual Optum/InterQual training.
- Complete the annual Optum/InterQual Interrater Reliability test and achieve the minimum passing score defined in yearly departmental goals.
- Meet weekly productivity metrics within 90 days of completing orientation and maintain them as defined in yearly departmental goals.
- Meet quality audit metrics within 90 days of completing orientation and maintain them according to the department's audit cadence and yearly goals.
- Complete required departmental education accurately and on time.
- Follow departmental workflows for 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, healthcare teams, 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
