Regional Care Manager
US-PA-Lemoyne
external
Req #: 183409
Type: Full-Time
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Overview: 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. 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: 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
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