Regional Care Manager (Midwest or Eastern Region) at Wellpath

Franklin, Tennessee, United States -

Full Time

Start Date

Immediate

Expiry Date

25 Mar, 26

Salary

0.0

Posted On

25 Dec, 25

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Utilization Review, Care Coordination, Clinical Reviews, InterQual Criteria, Pre-Certification, Case Management, Regulatory Compliance, Collaboration, Communication, Clinical Experience, Nursing Licensure, Computer Proficiency, Documentation, Best Practices, Healthcare, Compassion

Industry

Hospitals and Health Care

Description

Why Wellpath Now is your moment to make a difference in the lives of the underserved. If there is one unifying characteristic of everyone on our team, it is the deep desire to make a difference by helping society's most vulnerable and often overlooked individuals. Every day we have the distinct honor and responsibility to show up with non-judgmental compassion to provide hope and healing to those who need it most. For those whose calling it is to serve others, now is your moment to join our mission to provide quality care to every patient with compassion, collaboration, and innovation, to live our mantra to “Always Do The Right Thing!”, and to collectively do our part to heal the world, one patient at a time. Wellpath sees hundreds of thousands of unique individuals in their facilities month over month and a very large percent of those individuals receive direct clinical care, which includes lives saved by Narcan. We offer ongoing training and development opportunities for licensed and unlicensed healthcare team members, and have best in class clinical resources for training, education, and point of care support. About this role The Regional Care Manager (RCM) is responsible for utilization review, care coordination, and daily care management across multiple sites and states. This role ensures accurate and timely clinical reviews of off-site care, including observation, outpatient, and acute services. The RCM handles pre-certification for urgent, scheduled, and routine procedures while applying InterQual criteria and maintaining compliance with departmental policies. They collaborate with medical directors, site leadership, and care management teams to enhance best practices and regulatory compliance. This position requires frequent communication with clients, providers, and site personnel, as well as travel for meetings, training, and support as needed. What you bring to the table EDUCATION Graduation from an accredited School of Nursing or Care Management Certification RN preferred EXPERIENCE Previous utilization review and/or case management and pre-certification experience Knowledge of InterQual evidence-based guideline tools 3+ years of hands on clinical experience Computer proficiency with MS Word, Excel, and PowerPoint LICENSES/CERTIFICATIONS Current Nursing Licensure Case Management Certification preferred What you will do Conduct clinical reviews of off-site observation, outpatient, and acute care using InterQual criteria. Review and document concurrent clinical information in ERMA Care Management and Track Via systems, ensuring compliance with claims and medical review procedures. Manage pre-certification referrals for urgent, scheduled, and routine services including physician visits, procedures, imaging, and specialty care. Coordinate care with medical directors, site staff, and operations to ensure accuracy in utilization data and billing processes. Collaborate with the Care Management team to develop best practices, core competencies, and regulatory compliance procedures. We are an Equal Employment Opportunity Employer We are committed to fostering, cultivating, and preserving a culture of uniqueness. We celebrate a variety of backgrounds and are committed to creating an inclusive environment for all employees. We encourage you to apply! If you are excited about a role but your experience doesn’t seem to align perfectly with every element of the job description, we encourage you to apply. You may be just the right candidate for this, or one of our many other roles. Deadline to apply to this position is contingent upon applicant volume. Those positions located in Colorado will have a specific deadline posted in the job description. We are an Affirmative Action Employer in accordance with applicable state and local laws. We are an Equal Employment Opportunity Employer We are committed to fostering, cultivating, and preserving a culture of uniqueness. We celebrate a variety of backgrounds and are committed to creating an inclusive environment for all employees. We encourage you to apply! If you are excited about a role but your experience doesn’t seem to align perfectly with every element of the job description, we encourage you to apply. You may be just the right candidate for this, or one of our many other roles. Deadline to apply to this position is contingent upon applicant volume. Those positions located in Colorado will have a specific deadline posted in the job description. We are an Affirmative Action Employer in accordance with applicable state and local laws.

Responsibilities

The Regional Care Manager is responsible for utilization review, care coordination, and daily care management across multiple sites and states. They ensure accurate clinical reviews and manage pre-certification for various medical services while collaborating with medical directors and care management teams.