Regional Care Manager

Wellpath; Franklin (TN); Sur place; USD 70 000 - 95 000; Plein temps

Avantages offerts par ce poste

Comprehensive medical, dental, and vision benefits

Paid time off

401k

Tuition Assistance

Employee Assistance Program

Wellness program

DailyPay access

Résumé du poste

A healthcare organization in Tennessee is seeking a Regional Care Manager to coordinate care management across multiple locations. The ideal candidate will have experience in utilization review and hold a current nursing license. Responsibilities include managing clinical reviews using InterQual criteria, handling pre-certifications for procedures, and ensuring adherence to compliance standards. This role demands strong communication skills and a commitment to improving care delivery for underserved populations. A robust benefits package is offered, supporting work-life balance and professional development.

Qualifications

• 3+ years of hands-on clinical experience.
• Previous utilization review or case management experience required.
• Current Nursing Licensure necessary.

Responsabilités

• Conduct clinical reviews of off-site care using InterQual criteria.
• Manage pre-certification referrals for various services.
• Coordinate care with medical directors and site staff.
• Coordinate care with medical directors, site staff, and operations to ensure data accuracy and billing alignment.
• Develop best practices and regulatory compliance procedures with the Care Management team.

Connaissances

Utilization review knowledge

Clinical management skills

InterQual criteria familiarity

Communication skills

Computer proficiency

Formation

Graduation from an accredited School of Nursing

Care Management Certification

Outils

MS Word

Excel

PowerPoint

Description du poste

We\'re on a path to better healthcare.
Join us

• Make a difference every day in the lives of the underserved
• Join a mission driven organization with a people first culture
• Excellent career growth opportunities

Join us and find a career that supports:

• Caring for overlooked, underserved, and vulnerable patients
• Diversity, equity, inclusion, and belonging
• Autonomy in a warm team environment
• Growth and training

Perks and Benefits

In addition to comprehensive benefits including medical, dental, vision, paid time off, and 401k, we foster a work, life balance for team members and their family to support physical, mental, and financial wellbeing including:

• DailyPay, receive your money as you earn it!
• Tuition Assistance and dependent Scholarships
• Employee Assistance Program (EAP) including free counseling and health coaching
• Company paid life insurance
• Tax free Health Spending Accounts (HSA)
• Wellness program featuring fitness memberships and product discounts
• Preferred banking partnership and discounted rates for home and auto loans

*Eligibility for perks and benefits varies based on employee type and length of service.

Why Us

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.

Wellpath sees hundreds of thousands of unique individuals in their facilities month over month and a very large percent of those individuals receive direct clinical care, which includes lives saved by Narcan.

We offer ongoing training and development opportunities for licensed and unlicensed healthcare team members, and have best in class clinical resources for training, education, and point of care support.

How you make a difference

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.

Key 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.

Qualifications & Requirements

EDUCATION

• Graduation from an accredited School of Nursing or Care Management Certification
• RN preferred

EXPERIENCE

• 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

LICENSES/CERTIFICATIONS

• Current Nursing Licensure
• Case Management Certification preferred

We are an Equal Employment Opportunity/Affirmative Action Employer

We celebrate diversity and are committed to creating an inclusive environment for all employees.

If you are excited about a role but your experience doesn’t seem to align perfectly with every element of the job description, we encourage you to apply. You may be just the right candidate for this, or one of our many other roles.