RN Clinical Access & Utilization Case Manager

San Juan Regional Medical Center Inc.; United States; On-site; USD 68,000 - 92,000; Full time

Job summary

San Juan Regional Medical Center is seeking a Clinical Access Case Manager (CACM) to optimize patient flow and capacity management. You will coordinate with providers and the MRN to determine admission status and ensure robust utilization review and appeals processes.

Required is a current RN license in New Mexico with at least 3 years in acute care, plus strong communication, initiative, and teamwork. Preferred BSN, CM experience, and Accredited Case Manager Certification.

Qualifications

• Current RN license in the state of New Mexico.
• Minimum of three (3) years’ experience in acute care required.
• Assertive and diplomatic communication skills.
• Self-motivated and accountable.
• Team Oriented.

Responsibilities

• Management of ports of entry.
• Perform and document clinical reviews to determine medical necessity, using InterQual, and physician determination of length of stay (LOS).
• Collaborate with admitting provider, obtain and enter appropriate patient status orders in the EMR (i.e., inpatient, outpatient, or observation).
• Perform concurrent utilization review as assigned following contractual obligations.
• Denials and Appeals Management.
• Observation Management: Review observation cases every four (4) hours to assess for possible conversion to Inpatient or stability for discharge.
• Maintains accurate transfer and divert log.
• Supports EMTALA compliance.
• Maintain current knowledge of and follow Medicare and Medicaid requirements.
• Proactively identifying, documenting, and escalating problems with over/under utilization of hospital resources.
• Documents avoidable days as appropriate.
• Collaborates effectively with departmental staff to achieve goals and objectives.
• Utilizes internal or external Physician Advisor as needed to resolve level of care discrepancies.

Skills

Communication skills

Self-motivation

Team oriented

Education

Bachelor’s Degree (BSN)

Accredited Case Manager Certification

Tools

InterQual

EMR

Job description

San Juan Regional Medical Center is seeking a Clinical Access Case Manager (CACM) to optimize patient flow and capacity management. You will coordinate with providers and the MRN to determine admission status and ensure robust utilization review and appeals processes.

Required is a current RN license in New Mexico with at least 3 years in acute care, plus strong communication, initiative, and teamwork. Preferred BSN, CM experience, and Accredited Case Manager Certification.