Remote RN Care Manager – UM

Job Overview

  • Clinical License RN
  • State(s) Nationwide

About the job

Summary of Position:

  • Support the department’s quality of care and cost containment.
  • Provide utilization management as needed to ensure coordination of health care delivery.
  • Conduct medical appropriateness evaluations of acute care hospital admissions, post-acute care requests, and selected outpatient procedures. Facilitate the achievement of quality clinical outcomes by integrated and collaborative interventions with multiple disciplines, Pre/Post Service.
  • Ensure that members are receiving the appropriate level of care in the appropriate setting for the appropriate length of time within the established guidelines and benefit sets; Pre-service, Concurrent Review, Post-acute and Care Management. Work with interdisciplinary team to utilize the SNP members’ Plan of care to achieve improved health outcomes.

Principal Accountabilities

  • Utilize MCG, CMS Guidelines, medical and administrative policies to evaluate medical necessity.
  • Identify members at risk and refers for Care management and/or disease management as needed.
  • Assess and evaluate member’s needs, coordinate care utilizing approved criteria(s). (Include member and family discussion as necessary).
  • Maintain utilization time frames are met according to regulatory guidelines (i.e., initial determination decisions, adverse determination notification to providers and members).
  • Provide appropriate case review; ensure timely notification and correspondence to facilities, members and providers.
  • Utilize the member’s contract to determine coverage eligibility. Work with providers and take action in problem solving while exhibiting judgment and a realistic understanding of the issues.
  • Prepare and present clinical detail to the Medical Director for final case determination in accordance with regulation and department policy.
  • Ensure cost effectiveness and identified opportunities to reduce cost are captured (i.e. reinsurance reporting).
  • Refer to Medical Director any questionable quality issues or inappropriate hospitalizations for immediate intervention and/or refer cases that do not meet established criteria for approval of selected procedure or service.
  • Regular attendance is an essential function of the job. Perform other duties as assigned or required.

Education, Training, Licenses, Certifications:

  • Associates degree in nursing; bachelor’s preferred.
  • RN with an active, unrestricted nursing license (Concurrent Review, Medical Management, etc.)
  • MCG Certification preferred.
  • RN License in the state of New York (Required)

Relevant Work Experience, Knowledge, Skills, and Abilities:

  • 4 – 6 years of clinical experience.
  • Managed care experience.
  • Post-acute facility experience.
  • Care management experience.
  • Ability to work weekends and holidays on a rotating schedule.
  • Excellent communications skills (verbal, written, presentation, interpersonal).
  • Effectively able to screen and stratify members who are appropriate for care management services.
  • Ability to: manage a caseload of members in need of care management; and apply the care management process as outlined by the CMSA standards and clients’ policies.



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