RN, Care Manager, Utilization Management

Job Title

This position is in the ED. 12-hour shifts with rotating weekend and one 8-hour shift for a total of 80 hours per pay period. The salary range is $54.68 - $81.95/hour.

Job Summary

Plays a critical role in ensuring that patients receive high-quality care while efficiently utilizing medical resources. Reviews patient medical records, assessing the appropriateness and necessity of proposed treatments, and collaborating with healthcare providers and insurance companies to ensure a seamless care experience and the practicing of financial stewardship and denial prevention. Focuses on maximizing patient outcomes and optimizing resource allocation. Utilizes exceptional clinical knowledge, excellent communication skills, and the ability to thrive in a fast-paced and ever-changing healthcare environment.

Job Requirements

Education and Work Experience:

• 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, experience with Milliman Care Guidelines (MCG) UM chart review in EPIC within the last 12 months: Required

Licenses/Certifications:

• 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 to determine if the patient is in the right acute setting, receiving the right acute services, during the appropriate length of stay.
• Participates in annual Optum/Inter Qual training required. Takes the required annual Optum/Inter Qual Interrater Reliability (IRR) test with a minimum passing score as defined in the yearly departmental goals.
• Meets weekly productivity metrics within 90 days of completing orientation and maintains on a weekly basis as defined in the yearly departmental goals. Meets quality audit metrics within 90 days of completing orientation and maintained on the audit cadence set within the department as defined in the yearly departmental goals.
• Completes all required departmental education assigned with timeliness and accuracy. Follows all departmental workflows in communication variances to the on-site care management teams when appropriate. 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 to ensure a coordinated and efficient care process. Stays up to date with the latest healthcare regulations, insurance guidelines, and evidence-based practices to ensure the delivery of optimal healthcare services.
• Performs other job-related duties as assigned.

Organizational Requirements

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply. Adventist Health participates in E-Verify. Visit for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.

About Us

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.