Overview
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.
Responsibilities
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.
Qualifications
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