Care Manager, Utilization Management – Remote

Summary of Position:

The Care Manager, UM is responsible for supporting high-quality care delivery, ensuring cost containment, and managing utilization review functions. This role evaluates medical necessity, coordinates care, and works with interdisciplinary teams to promote positive health outcomes across pre-service, concurrent, post-acute, and care management activities.

Key Responsibilities:

• Support quality of care initiatives and cost management efforts.
• Conduct utilization management reviews for acute hospital admissions, post-acute requests, and outpatient procedures.
• Facilitate clinical outcomes through collaborative interventions with multiple disciplines.
• Ensure appropriate level of care, setting, and length of stay in alignment with guidelines and benefit structures.
• Apply MCG, CMS, and organizational policies to evaluate medical necessity.
• Identify at-risk members and refer for care or disease management as appropriate.
• Assess member needs and coordinate care, including discussions with members and families.
• Ensure regulatory timeframes are met for determinations and notifications.
• Provide case reviews, ensuring timely correspondence to members, providers, and facilities.
• Determine coverage eligibility based on member contracts and work with providers to resolve issues.
• Present clinical details to the Medical Director for case determinations.
• Monitor cost-effectiveness and identify opportunities to reduce unnecessary expenditures.
• Refer questionable quality issues or inappropriate hospitalizations to the Medical Director.
• Perform other related duties as required.

Qualifications:

Education, Training, Licenses, Certifications

• Associate degree in Nursing required; Bachelor’s preferred.
• RN with an active, unrestricted nursing license (Concurrent Review, Medical Management, etc.)
• MCG Certification preferred.

Experience, Knowledge, Skills, Abilities

• 4–6+ years of clinical experience.
• Experience in managed care and utilization management.
• Post-acute care facility or care management experience strongly preferred.
• Ability to work weekends and holidays on a rotating basis.
• Strong communication skills (verbal, written, presentation, interpersonal).
• Skilled in screening and stratifying members appropriate for care management.
• Ability to manage caseloads, create and execute care plans, and document per regulatory standards.
• Ability to coordinate with internal and external programs to meet member needs.
• Professional communication with members, providers, and interdisciplinary care teams

We are an equal opportunity employer and prohibit discrimination/harassment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

Job Type: Full-time

Pay: From $95,000.00 per year

Benefits:

• Dental insurance
• Health insurance
• Vision insurance

Application Question(s):

• Utilization Management operates 365 days a year, including weekends and holidays. This role requires participation in a rotating schedule. Are you able to accommodate this?
• I have my active RN license for the state I reside in.
• UM operates between standard business hours EST. This is a full-time position with an 8-hour shift. Does this align with your availability?

Work Location: Remote