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Utilization Care Manager Job
Job Number: RIH15953
Job Title: Utilization Care Manager
Department: Care Utilization Management - 1012285
Facility: Rhode Island Hospital
Location: Providence, RI
Bachelors Degree in Nursing required. Masters degree preferred.
Center Case Management (CCM) ® board certification or Accredited Case Manager (ACM ™) is highly desirable.
A current licensure to practice as a Registered Nurse in the State of Rhode Island or in another state that participates in the Nurse Licensure Compact is required
Five years relevant clinical experience with recent experience with utilization review, case management, patient navigation or discharge planning is strongly preferred.
Strong analytical and interpersonal skills are required to provide guidance to and communicate daily with healthcare professionals, patients and families.
Must exhibit a collaborative approach and method of communication in order to interact successfully on as daily basis with a wide and diverse population of both health care providers, insurers, patients and their families.
Familiarity with InterQual™ care management criteria is required. Has a high level of knowledge concerning utilization review, healthcare finance and the requirements of relevant payers.
Demonstrates knowledge and skills necessary to provide care to patients throughout the life span, with consideration of aging processes, human development stages and cultural patterns in each step of the care process.
Must be proficient in the use of Microsoft Office software including email and outlook calendar, and have basic keyboarding skills.
The Utilization Care Manager reports to the Manager of Utilization Management or Director of Care Management for Lifespan and is responsible for conducting surveillance over medical necessity of patient care records. In collaboration with the physician of record and the Utilization Review Committee physician, ensures the appropriate level of patient care is provided and that admission and concurrent authorizations from third party payers are obtained. In collaboration with the Care Coordination Manager and other members of the healthcare team, monitors and ensures appropriate and timely utilization of resources and services so that patients receive high quality, safe and fiscally responsible care.