RN, Care Manager, Utilization Management

United States Digital Space LLC; United States; Remote; USD 90,000 - 120,000; Full time

Job summary

United States Digital Space LLC in Roseville, California seeks a skilled RN to manage utilization review for acute care. You will review medical records, determine appropriate settings and length of stay, and collaborate with healthcare providers and insurers to optimize care and resource use.

Requires an RN license, an Associate’s degree minimum, five years of acute hospital experience, and two years using Optum/InterQual. BSN preferred.

Qualifications

• Associate’s Degree in nursing or equivalent required.
• BSN preferred.
• Five years' acute hospital experience required; critical care experience preferred.
• Two years' utilization review experience using the Optum/Inter Qual product within the last 12 months.

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 and IRR test with a minimum passing score.
• Meets weekly productivity metrics within 90 days of orientation and maintains on a weekly basis as defined in the goals.
• 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 and coordinates with insurers.
• Performs other job-related duties as assigned.

Skills

Clinical knowledge

Communication skills

Fast-paced environment

Attention to detail

Education

Associate's Degree in Nursing

BSN preferred

Tools

Optum/InterQual

Job description

Located in the metropolitan area of Sacramento, the the company corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect.

Whether virtual or on campus, the company Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work.

Job Summary:

Plays a critical role in ensuring that patients receive high-quality care while efficiently utilizing medical resources. Reviews patient medical records, assessing the appropriateness and necessity of proposed treatments, and collaborating with healthcare providers and insurance companies to ensure a seamless care experience and the practicing of financial stewardship and denial prevention. Focuses on maximizing patient outcomes and optimizing resource allocation. Utilizes exceptional clinical knowledge, excellent communication skills, and the ability to thrive in a fast-paced and ever-changing healthcare environment.

Job Requirements:Education and Work Experience:

• Associate’s Degree in nursing or equivalent combination of education/related experience: Required
• Bachelor's Degree in Nursing (BSN): Preferred
• Five years' acute hospital experience required with preferred experience in critical care areas: Required
• Two years' utilization review experience using the Optum/Inter Qual product within the last 12 months: Required

Licenses/Certifications:

• Registered Nurse (RN) licensure in the state of practice: Required

Essential Functions:

• 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.

Organizational Requirements:

the company is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.

the company participates in E-Verify. Visit for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.

Originally posted on Himalayas