RN Utilization Review Care Manager PRN

Intermountain Healthcare Inc.; Austin (TX); Remote; USD 57,000 - 86,000; Part time

Job summary

Intermountain Health is seeking an RN Utilization Review Care Management I for St. Marys Regional Hospital. This fully remote role involves coordinating utilization reviews, applying evidence-based guidelines, and ensuring compliant, cost-effective care.

Flexible options and strong collaboration with providers, patients, and payers are essential. Position details include average 2 days per week plus 2 weekends every 8 weeks, with holiday coverage and a compact license.

Qualifications

• Active RN license in state of practice with compact licensure within service area.
• BSN required within four years of hire or promotion.
• Experience in care management/navigation or related field.
• Inpatient hospital nursing experience and familiarity with hospital terminology.
• Understanding of disease management, barriers to care, and variation.
• Strong written, verbal communication and conflict resolution skills.
• Proficient with computers and MS Office; able to troubleshoot independently.
• Ability to work independently in a dynamic environment.

Responsibilities

• Reviews and investigates medical records to ensure appropriate benefit utilization and medical necessity.
• Applies guidelines (e.g., InterQual/MCG) and policies for prior authorization and post-service reviews.
• Adheres to regulatory requirements and communicates timely with members and providers.
• Engages with providers to ensure safe, efficient care and appropriate settings.
• Collaborates with physicians, staff, members, and families to expedite authorizations.
• Engages with members/providers for continuity of care and authorization determinations.
• Resolves questions regarding authorizations and treatment plans.
• Mentors UM LPN and non-clinical staff on processes and resources.

Skills

Utilization Management

Clinical Expertise

Investigative Acumen

Medical Diagnosis

Medical Terminology

Time Management

Problem Solving

Quality Care

Communication

Education

RN license in state

Compact licensure within service area

BSN within 4 years of hire

Tools

Microsoft Office

Microsoft Teams

Job description

Fully Remote

St. Marys Regional Hospital

Part time

R189124

Job Description

The RN Utilization Review Care Management I leverages clinical expertise and critical thinking to perform utilization review care management screenings, assessments, and evaluations, with a strong focus on resource stewardship. This role involves developing and implementing plans that promote cost-effective, high-quality care. Collaboration with patients, their families or significant others, healthcare providers, insurers, and other involved parties is essential to ensure compliant, efficient, effective, and patient-centered utilization review services.

We are committed to offering flexible work options where approved and stated in the job posting. However, we are currently not considering candidates who reside or plan to reside in the following states: California, Connecticut, Hawaii, Illinois, Massachusetts, Maine, Minnesota, New York, Pennsylvania, Rhode Island, Virginia Vermont, Washington.

Please note that a video interview through Microsoft Teams will be required.

Position Details

• Shift coverage enterprise wide - Peaks/Canyons/Desert regions
• Average 2 days per week; 2 weekends per 8-week schedule
• Holiday coverage is also required
• RN Licensure with compact required
• 8:00 AM - 5:00 PM

Essential Functions

• Reviews and investigates medical records and applies clinical expertise to assure appropriate benefit utilization and medical necessity as relates to requested services, authorization history, and treatment plan.
• Uses in-depth knowledge of medical procedures, treatments, and diagnosis to apply evidence-based guidelines (e.g. InterQual/MCG) and medical policies for prior authorization and post service reviews.
• Follows the applicable regulatory guidelines (NCQA, CMS, State, plan) and ensures timely review with clear and accurate communication to members and requesting providers. Adheres to regulatory guidelines and timely communication with members, providers, and internal/external partners.
• Based on medical necessity and clinical best practice, proactively engages with providers to ensure safe and efficient medical care, appropriate care setting, and safe transitions of care referring to alternate programs as applicable.
• Collaborates with physicians, internal staff, members, and families to assist in expediting the requested authorizations, and directs toward medically necessary care and the correct level/setting for services requested.
• Engage proactively with members and providers for safe, efficient care and transitions as applicable to continuity of care, redirection, and authorization determination.
• Resolves queries regarding authorizations, treatment plans, and medical necessity determinations.
• Mentors and guides the UM LPN & non-clinical on process/clinical questions and application of resources.

Skills

• Utilization Management
• Clinical Expertise
• Investigative Acumen
• Medical Diagnosis & Treatment
• Medical Terminology
• Time Management
• Problem Solving
• Quality Care
• Communication

Minimum Qualifications

• Current Registered Nurse (RN) license in state of practice, and compact licensure within service area.
• Bachelor of Science in Nursing (BSN) from an accredited institution (degree verification required). RNs hired or promoted into this role must obtain their BSN within four (4) years of hire or promotion date.
• Demonstrated experience in care management/navigation or closely related field including: Utilization Management, discharge planning, managed care, health promotion, health coaching, behavioral health, or Patient Educator job role.
• Demonstrated clinical nursing experience in an inpatient hospital setting, and familiarity with hospital patient-related terminology and processes.
• Demonstrated understand of disease management including treatment, length of stay, identifying barriers to delivery of care and any variation.
• Strong written, verbal communication and conflict resolution skills
• Basic computer hardware set-up, ability to customize computer settings and use multiple monitors and capable of independent troubleshooting internet and applications. Knowledge of Microsoft Office software.
• Ability to work independently, be self-motivated, have a positive attitude, and be flexible in a rapidly changing environment.
• Strong written, verbal communication and conflict resolution skills

Preferred Qualifications

• One (1) year experience in care management/navigation or closely related field including: Utilization Management, discharge planning, managed care, health promotion, health coaching, behavioral health, or Patient Educator job role.
• Three (3) years of experience and expertise working in clinical nursing in an ambulatory care setting, community health or home care.
• Bachelor’s degree in nursing (BSN) from an accredited institution (degree will be verified).
• Case management or utilization, or health care quality certification
• Previous experience working with third party payers.
• Ability to work independently and be flexible in a rapidly changing environment.
• Experience working successfully working in a remote environment or using Advanced Microsoft Suite, including Teams (chat, whiteboard, task tracking) & Outlook.

Physical Requirements

• Ongoing need for employee to see and read information, labels, documents, monitors, identify equipment and supplies, and be able to assess customer needs.
• Frequent interactions with providers, colleagues, customers, patients/clients and visitors that require employee to verbally communicate as well as hear and understand spoken information, needs, and issues quickly and accurately.
• Manual dexterity of hands and fingers to manipulate complex and delicate supplies and equipment with precision and accuracy. This includes frequent computer use for typing, accessing needed information, etc.
• For roles requiring driving: Expected to drive a vehicle which requires sitting, seeing and reading signs, traffic signals, and other vehicles.

Location

St. Marys Regional Hospital

Work City

Grand Junction

Work State

Colorado

Scheduled Weekly Hours

0

The hourly range for this position is listed below. Actual hourly rate dependent upon experience.

$41.20 - $62.17

We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.

Learn more about our comprehensive benefits package here (https://intermountainhealthcare.org/careers/benefits) .

Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

Intermountain Health’s PEAK program supports caregivers in the pursuit of their education goals and career aspirations by providing up-front tuition coverage paid directly to the academic institution. The program offers 100+ learning options to choose from, including undergraduate studies, high school diplomas, and professional skills and certificates. Caregivers are eligible to participate in PEAK on day 1 of employment. Learn more. (https://intermountainhealthcare.org/careers/working-for-intermountain/employee-benefits/peak-program/)

The primary intent of this job description is to set a fair and equitable rate of pay for this classification. Only those key duties necessary for proper job evaluation and/or labor market analysis have been included. Other duties may be assigned by the supervisor.

All positions subject to close without notice.

Headquartered in Utah with locations in six primary states and additional operations across the western U.S., Intermountain Health is a nonprofit system of 34 hospitals, 400+ clinics, a medical group of more than 4,800 employed physicians and advanced care providers, a health plan division called Select Health with more than one million members, and other health services. Helping people live the healthiest lives possible, Intermountain is widely recognized as a leader in clinical quality improvement and efficient healthcare delivery.

Join our world-class team and embark on a career filled with opportunities, strength, innovation, and fulfillment.

To find out more about us, head to our career site here (https://intermountainhealthcare.org/careers/?utm_source=Workday&utm_medium=Redirect&utm_campaign=CareerHome_workday) .

Intermountain Health strives to make the application process accessible to all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact 1-800-843-7820 or email [e-mail] . This contact information is for accommodation requests only and cannot be used to inquire about the status of applications.

All positions subject to close without notice.

Thanks for your interest in continuing your career with our team!