Job Description

Registered Nurse (RN) Care Manager / Utilization Review

Specialty: Nursing

Sub Specialty: Care Manager

Shift: To Be Discussed During Interview

Important Requirements

• Active Alaska RN License is required at the time of submission.
• Flu vaccination is required.
• Start date will be no sooner than 6 weeks after fingerprint cards are received for processing.
• Upon acceptance, fingerprint appointments should be completed and mailed within 2 3 days to avoid delays in the contract start date.

Position Summary

The Care Manager is responsible for managing patient progression of care, coordinating utilization management activities, promoting evidence-based care, ensuring appropriate resource utilization, and facilitating timely patient discharge. This role collaborates with physicians, clinical teams, leadership, payers, and regulatory agencies to ensure medically necessary, cost-effective, and compliant patient care.

Key Responsibilities

• Review patient records to evaluate medical necessity, level of care, length of stay, and quality of care.
• Monitor patient progression and facilitate timely, appropriate discharge planning.
• Perform utilization management (UM), case management (CM), and discharge planning activities.
• Review hospital admissions and develop individualized care plans.
• Coordinate care with physicians, leadership, interdisciplinary teams, and external providers.
• Obtain and review medical reports and treatment plans for regulatory agencies and payers.
• Validate physician orders and monitor patient progress.
• Ensure documentation supports utilization review requirements and payer guidelines.
• Communicate with insurance payers within required timeframes.
• Process denial appeals and maintain utilization review and appeal logs.
• Prepare notification letters for providers, staff, and patients.
• Provide education regarding healthcare benefits and utilization management requirements.
• Support quality improvement initiatives through clinical quality review.
• Perform tumor registry functions as assigned.

Required Qualifications

Education

• Bachelor's Degree in Nursing (BSN).
• High School Diploma or equivalent.

Experience

• Minimum 8 years of clinical nursing experience .
• Minimum 3 years of experience in chart review, utilization review, risk management, case management, or related quality services .

Licensure

• Active Alaska Registered Nurse (RN) License (required at submission).

Preferred Certification

• Case Management Certification through a recognized organization (e.g., CCMC or NCQA ).

Required Certification

• BLS.

Knowledge & Skills

• Utilization management and case management principles.
• Medical necessity review and reimbursement guidelines.
• ICD-9 and CPT coding fundamentals.
• CMS regulations and payer requirements.
• Medical terminology, anatomy, physiology, and disease processes.
• Strong assessment, communication, organizational, and interdisciplinary collaboration skills.

Schedule

• Schedule to be discussed during the interview.

General Certifications

• BLS/BCLS

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