Case Management Utilization Review RN – REMOTE ID-4026

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Care Manager Position

Key Responsibilities:

  • Assess, plan, implement, evaluate, and coordinate patient care from pre-hospital to post-hospital care using a systematic approach.
  • Develop physician profiles to identify utilization patterns (over/under).
  • Support the goals of Steward Health Care and comply with regulatory standards.
  • Collaborate with healthcare professionals to ensure timely, quality care.
  • Evaluate the medical appropriateness, quality, and cost-effectiveness of hospital, medical, and surgical services.
  • Work with the multidisciplinary team to manage patient benefits and obtain authorization from payers.
  • Develop strategies to optimize inpatient length of stay and resource use.

Required Knowledge & Skills:

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  • Competency with computer-based charting and clinical/non-clinical software.
  • Ability to adapt to change and demonstrate strong organizational skills.
  • Effective reading, communication, and presentation skills.
  • Knowledge of Medicare, Medicaid, HMO, and private insurance criteria.
  • Critical thinking and patient advocacy skills.
  • Leadership qualities: mentoring, coaching, time management, and problem-solving.
  • Proactive approach to problem resolution and ability to work in a fast-paced environment.
  • Proficient in Microsoft Office (Excel, Word, etc.).
  • Understanding of clinical criteria, CMI, patient status, InterQual, Milliman Criteria, and Transfer DRGs.
  • Ability to work independently and remotely.

Education/Experience/Certification:

  • Education: Bachelor’s degree required; Master’s degree preferred.
  • Experience: 3-5 years of acute medical/surgical experience + 3-5 years of Case Management experience.
  • Licensure/Certification: RN license required; Certification in Case Management (CCM) strongly preferred.
  • Technical Skills: Strong knowledge of Microsoft Office Suite (Word, Excel, Access, PowerPoint).
  • Other: Knowledge of healthcare delivery settings and industry standards.

This Care Manager position offers an opportunity to collaborate with a multidisciplinary team, support patients through their hospital stay, and ensure the efficient use of healthcare resources. Strong communication, organizational, and leadership skills are crucial in this fast-paced environment.

Case Management Utilization Review RN – REMOTE ID-4026

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