Regional Care Manager (Midwest or Eastern Region)

Wellpath; Franklin (TN); On-site; USD 75,000 - 90,000; Full time

Job summary

A healthcare organization is seeking a Regional Care Manager in Tennessee to oversee utilization reviews and care coordination across multiple sites. The role demands a strong nursing background with at least 3 years of clinical experience and expertise in InterQual criteria. Responsibilities include managing pre-certification referrals, conducting clinical reviews, and fostering collaboration with medical teams. This position offers the opportunity to make a difference in the lives of underserved patients within a dynamic environment.

Qualifications

• Previous utilization review and/or case management experience.
• Knowledge of InterQual evidence-based guideline tools.
• 3+ years of hands-on clinical experience.
• Current Nursing Licensure and preferred Case Management Certification.

Responsibilities

• Conduct clinical reviews of off-site observation, outpatient, and acute care.
• Review and document clinical information in required systems.
• Manage pre-certification referrals for various services.
• Coordinate care with medical directors and site staff.
• Collaborate with the Care Management team to develop best practices.

Skills

Utilization review

Care coordination

Clinical experience

InterQual criteria

Communication

Team collaboration

Education

Graduation from an accredited School of Nursing

Tools

MS Word

Excel

PowerPoint

Job description

Regional Care Manager (Midwest or Eastern Region)

We are on a path to better healthcare and invite you to join a mission‑driven organization focused on underserved patients.

Overview

• Make a difference every day in the lives of the underserved
• Join a people‑first culture that values compassion, collaboration, and innovation
• Enjoy excellent career growth opportunities

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. The RCM handles pre‑certification for urgent, scheduled, and routine procedures while applying InterQual criteria and maintaining compliance with departmental policies. The RCM collaborates with medical directors, site leadership, and care management teams to enhance best practices and regulatory compliance. The role 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

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.