Care Manager II (RN): Hoag Orthopedic Institute Care Management

Primary Duties and Responsibilities

The Care Manager (RN) utilizes clinical expertise, patient assessments, and insurance payer requirements to coordinate patients’ needs through the continuum of care including post-acute care and discharge plans. This role includes reviewing clinician assessments and patients’ financial, family and psychosocial support to justify hospitalization for clinical reviews.  Duties include reviewing records to assess appropriate admission status, level of care, payer source, and UR contracts to validate billing.  Documents pertinent patient issues, contacts and discharge plans on medical reviews. Communicates with physicians and medical offices to confirm appropriate insurance authorizations are in place.  Assists with providing proper justification for insurance appeals and denials as needed. May educate patients and families on appropriate level of care changes.

Education and Experience

• Five years of clinical experience in an acute healthcare system environment.
• Experience in Interqual or Millennium Guidelines required.
• One year of experience in utilization review required.
• Experience with healthcare database systems
• Care Manager II (RN) – Bachelor’s or Master’s degree in Nursing (BSN/MSN).

License Required

• Registered Nurse (RN) license for Care Manager II (RN) position

License Preferred

• N/A

Certifications Required

• N/A

Certifications Preferred

• Utilization Review
• Care Management
• Clinical Nursing