[Hiring] RN, Care Manager, Utilization Management @Adventist Health

Role Description

This role plays a critical part in ensuring that patients receive high-quality care while efficiently utilizing medical resources.

• Reviews patient medical records to assess the appropriateness and necessity of proposed treatments
• Collaborates with healthcare providers and insurance companies to ensure a seamless care experience
• Focuses on maximizing patient outcomes and optimizing resource allocation
• Utilizes exceptional clinical knowledge and excellent communication skills
• Thrives in a fast-paced and ever-changing healthcare environment

Qualifications

• 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

Requirements

• 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
• Participates in annual Optum/Inter Qual training required
• Takes the required annual Optum/Inter Qual Interrater Reliability (IRR) test with a minimum passing score
• Meets weekly productivity metrics within 90 days of completing orientation
• Maintains quality audit metrics within 90 days of completing orientation
• Completes all required departmental education assigned with timeliness and accuracy
• Follows all departmental workflows in communication variances to the on-site care management teams
• 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
• Stays up to date with the latest healthcare regulations, insurance guidelines, and evidence-based practices
• Performs other job-related duties as assigned

Organizational Requirements

• Adventist Health is committed to the safety and wellbeing of our associates and patients
• All associates must receive all required vaccinations as a condition of employment
• Medical and religious exemptions may apply
• Adventist Health participates in E-Verify