Care Manager, Concurrent Review (Remote)

Summary of Position
* Perform clinical reviews within the Medical Management Operations Concurrent Review utilization management department.
* Ensure accurate administration of benefits, execution of clinical policy and timely access to appropriate levels of care.
Principal Accountabilities
* Under the direction of the leader, is responsible for the execution of efficient departmental processes designed to manage inpatient utilization within the benefit plan.
* Act as the clinical coordinator collaborating with members and facilities to evaluate member needs within the inpatient setting.
* Establish and maintain active working relationships with assigned facility care managers/utilization management departments to facilitate appropriate clinical reviews and patient care.
* Enter and maintain documentation in the TPH platform meeting defined timeframes and performance standards.
* Communicate authorization decisions and important benefit information to providers and members in accordance with applicable federal and state regulations, and NCQA and business standards.
* Review and investigate member and provider requests to determine appropriate utilization of benefits and/or claim adjudication.
* Research evidence-based guidelines, medical protocols, provider networks, and on-line resources in making coverage determinations and recommendations.
* Prepare and present clinical case summaries in routine inpatient rounds.
* Maintain an understanding of utilization management, program objectives and design, implementation, management, monitoring, and reporting.
* Identify quality, cost and efficiency trends and provide solution recommendations to Supervisor/Manager.
* Actively participate on assigned committees.
* Perform other related projects and duties as assigned.
Qualifications
Education, Training, Licenses, Certifications
* Associate's degree or bachelor's degree in nursing.
* Valid RN License without restriction.
* May require a CME accreditation in specific specialties.
* Certification in utilization or care management preferred
Relevant Work Experience, Knowledge, Skills, and Abilities
* 4 - 6+ years of Nursing experience.
* Case and/or utilization management/care coordination and managed care experience.
* Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audience.
* Organizing and prioritizing skills, and strong attention to detail.
* Trained in the use of Motivational Interviewing techniques.
* Experience working in physician practice and/or with electronic medical records.
* Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.).
* Proficiency with the use of mobile technology (Smartphone, wireless laptop, etc.).
Additional Information
* Requisition ID: 1000002996
* Hiring Range: $68,040-$118,800