Regional Care Manager - Remote PRN

at  Wellpath

You Matter:

• Make a difference every day in the lives of the underserved
• Join a mission driven organization with a people first culture
• Excellent career growth opportunities

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.
How you make a difference:
The Regional Care Manager (RCM) works collaboratively with the Utilization Medical Director, Regional Medical Directors, and Site Leadership to oversee utilization review, daily care management, and care coordination for multiple sites and states. This role is responsible for analyzing and supporting off-site medical care during an inmate’s stay in the acute care setting. The RCM plays a crucial role in ensuring quality care for inmates and promoting efficient and effective use of resources across the correctional healthcare system.

Key Responsibilities:

• Conduct clinical review and apply InterQual Criteria for off-site observation, outpatient, and acute care as per department procedures.
• Review and document concurrent clinical information in the ERMA Care Management System, and comply with tracking and following the Medical Review procedure, including claims holds.
• Review and pre-certify referrals for outpatient physician visits, office procedures, surgical procedures, imaging, and specialty services, including urgent, scheduled, and routine cases.
• Coordinate care with Regional Medical Directors, Site Medical Directors, and Operations personnel as needed, while routinely reviewing utilization entries for accuracy.
• Collaborate with Care Management team to develop core competencies, best practices, policies, and procedures, including regulatory compliance, while using the Customer Liability Matrix for billing information.

Qualifications & Requirements:

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 specific skill in MS word, Excel, and Power Point.

Licenses/Certifications

• Current Nursing Licensure
• Case Management Certification preferred

Additional Details : Remote position PRN position, covering people out on PTO or taking extended time off
We are an Equal Employment Opportunity / Affirmative Action Employer:
We celebrate diversity 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

• Conduct clinical review and apply InterQual Criteria for off-site observation, outpatient, and acute care as per department procedures.
• Review and document concurrent clinical information in the ERMA Care Management System, and comply with tracking and following the Medical Review procedure, including claims holds.
• Review and pre-certify referrals for outpatient physician visits, office procedures, surgical procedures, imaging, and specialty services, including urgent, scheduled, and routine cases.
• Coordinate care with Regional Medical Directors, Site Medical Directors, and Operations personnel as needed, while routinely reviewing utilization entries for accuracy.
• Collaborate with Care Management team to develop core competencies, best practices, policies, and procedures, including regulatory compliance, while using the Customer Liability Matrix for billing information