Care Manager

Care Manager

Specialty: Nursing



Sub Specialty: Care Manager



Shift: To be discussed at interview

Important Requirements

• Must have an active Alaska nursing license at time of submission.
• Flu vaccine required.
• Minimum 8 years of clinical care or nursing experience.
• At least 3 years of experience in chart review, risk management, or related quality service.
• Fingerprint cards required for processing prior to start.
• Start date will be no less than 6 weeks after fingerprint cards are received for processing.

Position Summary

The Care Manager manages patient progression of care, utilization management, and care coordination for hospitalized patients. The role evaluates medical necessity, appropriateness of hospitalization, length of stay, quality of care, and discharge planning while collaborating with physicians, clinical teams, leadership, payers, and regulatory agencies to support evidence-based, appropriate, and cost-effective care.

Key Responsibilities

• Review patient records and evaluate patient progress.
• Conduct continued reviews of hospitalization for medical necessity, appropriateness, length of stay, and quality of care.
• Perform utilization management and review functions for referred or purchased care patients admitted to other facilities.
• Obtain and review medical reports and treatment plans requested by regulatory agencies or payers.
• Review and validate physician orders and report patient progress and unusual occurrences.
• Collaborate with physicians, leadership, and clinical care teams to ensure healthcare services are appropriate and cost-effective.
• Develop personalized treatment plans based on patient conditions and needs.
• Provide patients and families with information regarding healthcare benefits.
• Participate in interdisciplinary collaboration.
• Maintain the Utilization Review Plan in collaboration with utilization review staff and the Medical Director or designated provider.
• Provide education regarding regulations affecting utilization management, case management, and discharge planning.
• Coordinate patient care departments to ensure treatment plans meet patient needs and applicable hospital, regulatory, and payer requirements.
• Ensure documentation supports utilization management functions.
• Communicate with payers within required timeframes.
• Review information and communicate results to claims adjusters.
• Enter appropriate billing information.
• Prepare notification letters for providers, staff, and patients.
• Receive and process requests for appeals of denials.
• Respond to complaints according to utilization review guidelines.
• Maintain utilization review and appeal logs.
• Support clinical improvement activities through quality review.
• Perform tumor registry functions.
• Perform other duties as assigned.

Required Qualifications

Education

• Bachelor's degree in Nursing.
• High school diploma or equivalent.

Experience

• 8 years of clinical care or nursing experience.
• 3 years of experience in chart review, risk management, or related quality service.

Licensure

• Active Alaska nursing license.

Preferred Qualifications

• Case Management certification from a recognized certifying organization, such as NCQA or CCMC.

Schedule

• Schedule to be discussed at interview.

General Certifications

• BLS/BCLS
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