The Utilization Care Manager contributes to the hospital's Utilization Management Program by determining appropriateness for inpatient level of care or observation services based on clinical information and payer guidelines
Job Summary
The Utilization Care Manager contributes to the hospital's Utilization Management Program by determining appropriateness for inpatient level of care or observation services based on clinical information and payer 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, full-time with regular scheduled hours and requires successful completion of background checks and possibly drug screening or physical exams.
Matching Summary
The Utilization Care Manager contributes to the hospital's Utilization Management Program by determining appropriateness for inpatient level of care or observation services based on clinical information and payer guidelines.
Skills & Requirements
Must-have
Medical necessity guidelines application
Utilization Management compliance
Inpatient and observation care assessment
Knowledge of CMS and payer requirements
Remote work capability
Nice-to-have
Awareness of State and National healthcare trends
Familiarity with TJC and third party payor guidelines
Ability to review clinical documentation
Key Requirements
Bachelor's degree in Nursing
RN licensure
Two years Care Management or Utilization Management experience