The Utilization Care Manager contributes to the hospital's Utilization Management Program by determining appropriateness for inpatient or observation services using medical necessity guidelines
Job Summary
The Utilization Care Manager contributes to the hospital's Utilization Management Program by determining appropriateness for inpatient or observation services using medical necessity guidelines.
This role requires in-depth knowledge of payer rules, regulations, and MCG guidelines to ensure compliance with CMS and other third party payor requirements.
The position is remote, regular full-time with a first shift schedule, and final candidates must pass a background check with possible drug screening or physical.
Matching Summary
The Utilization Care Manager contributes to the hospital's Utilization Management Program by determining appropriateness for inpatient or observation services using medical necessity guidelines.
Skills & Requirements
Must-have
Medical necessity guideline application
Utilization management compliance
Knowledge of CMS and payer rules
Care management services
Remote work environment
Nice-to-have
Awareness of State and National healthcare trends
Familiarity with TJC and third party payor guidelines
Ability to apply MCG guidelines
Key Requirements
Bachelor's degree in Nursing
RN licensure
Two years Care Management or Utilization Management experience