Adventist Health is a faith-based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of more than 38,000 includes employees, physicians, Medical Staff, and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.
RN, Care Manager, Utilization Management
Location
United States
Posted
15 days ago
Salary
Not specified
No structured requirement data.
Job Description
Role Description
This role plays a critical part in ensuring that patients receive high-quality care while efficiently utilizing medical resources.
- Reviews patient medical records to assess the appropriateness and necessity of proposed treatments
- Collaborates with healthcare providers and insurance companies to ensure a seamless care experience
- Focuses on maximizing patient outcomes and optimizing resource allocation
- Utilizes exceptional clinical knowledge and excellent communication skills
- Thrives in a fast-paced and ever-changing healthcare environment
Qualifications
- Associate's Degree in nursing or equivalent combination of education/related experience: Required
- Bachelor's Degree in Nursing (BSN): Preferred
- Five years' acute hospital experience required with preferred experience in critical care areas: Required
- Two years' utilization review experience using the Optum/Inter Qual product within the last 12 months: Required
Requirements
- Registered Nurse (RN) licensure in the state of practice: Required
Essential Functions
- Completes clinical reviews of acute medical patients using the Optum/Inter Qual tool
- Participates in annual Optum/Inter Qual training required
- Takes the required annual Optum/Inter Qual Interrater Reliability (IRR) test with a minimum passing score
- Meets weekly productivity metrics within 90 days of completing orientation
- Maintains quality audit metrics within 90 days of completing orientation
- Completes all required departmental education assigned with timeliness and accuracy
- Follows all departmental workflows in communication variances to the on-site care management teams
- Reviews and analyzes medical records to assess the necessity and appropriateness of treatments and interventions
- Collaborates with healthcare professionals to develop and implement comprehensive patient care plans
- Facilitates communication between the patient, healthcare team, insurance providers, and other stakeholders
- Stays up to date with the latest healthcare regulations, insurance guidelines, and evidence-based practices
- Performs other job-related duties as assigned
Organizational Requirements
- Adventist Health is committed to the safety and wellbeing of our associates and patients
- All associates must receive all required vaccinations as a condition of employment
- Medical and religious exemptions may apply
- Adventist Health participates in E-Verify
Job Requirements
- Associate's Degree in nursing or equivalent combination of education/related experience: Required
- Bachelor's Degree in Nursing (BSN): Preferred
- Five years' acute hospital experience required with preferred experience in critical care areas: Required
- Two years' utilization review experience using the Optum/Inter Qual product within the last 12 months: Required
- Registered Nurse (RN) licensure in the state of practice: Required
- Essential Functions
- Completes clinical reviews of acute medical patients using the Optum/Inter Qual tool
- Participates in annual Optum/Inter Qual training required
- Takes the required annual Optum/Inter Qual Interrater Reliability (IRR) test with a minimum passing score
- Meets weekly productivity metrics within 90 days of completing orientation
- Maintains quality audit metrics within 90 days of completing orientation
- Completes all required departmental education assigned with timeliness and accuracy
- Follows all departmental workflows in communication variances to the on-site care management teams
- Reviews and analyzes medical records to assess the necessity and appropriateness of treatments and interventions
- Collaborates with healthcare professionals to develop and implement comprehensive patient care plans
- Facilitates communication between the patient, healthcare team, insurance providers, and other stakeholders
- Stays up to date with the latest healthcare regulations, insurance guidelines, and evidence-based practices
- Performs other job-related duties as assigned
- Organizational Requirements
- Adventist Health is committed to the safety and wellbeing of our associates and patients
- All associates must receive all required vaccinations as a condition of employment
- Medical and religious exemptions may apply
- Adventist Health participates in E-Verify
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