Utilization Care Manager - Rn

The Ohio State University

Fully remote
Medical necessity guideline application
Knowledge of cms and payer requirements
Utilization management program execution
The Utilization Care Manager contributes to the hospital's Utilization Management Program by determining appropriateness for inpatient or observation services based on clinical information and compliance with CMS and payer guidelines

Job Summary

  • The Utilization Care Manager contributes to the hospital's Utilization Management Program by determining appropriateness for inpatient or observation services based on clinical information and compliance with CMS and payer guidelines.
  • This role requires in-depth knowledge and application of various payer rules, regulations, and MCG guidelines while maintaining awareness of healthcare trends and accreditation standards.
  • The position is remote, full-time with a first shift schedule, and final candidates must successfully complete a background check and potentially a drug screen or physical.

Matching Summary

The Utilization Care Manager contributes to the hospital's Utilization Management Program by determining appropriateness for inpatient or observation services based on clinical information and compliance with CMS and payer guidelines.

Skills & Requirements

Must-have

  • Medical necessity guideline application
  • Knowledge of CMS and payer requirements
  • Utilization management program execution
  • In-depth payer rules and MCG guidelines
  • Remote work capability
  • Care management experience

Nice-to-have

  • Awareness of State and National healthcare trends
  • Familiarity with TJC and third party payor guidelines
  • Background check compliance

Key Requirements

  • Bachelor's degree in Nursing
  • RN licensure
  • Two years Care Management or Utilization Management experience

Work Rights

Not specified

Tailored Resume

Cover Letter