Care Manager RN (Utilization Management)

TL;DR

Care Manager RN (Utilization Management): Implementing effective utilization management strategies and reviewing the appropriateness of healthcare services with an accent on regulatory compliance and clinical quality. Focus on analyzing qualitative and quantitative data to improve provider performance and member health outcomes.

Location: Must be based in Pennsylvania

Company

hirify.global is a national health and wellness organization providing comprehensive healthcare services.

What you will do

• Implement care management review processes consistent with industry and corporate standards.
• Review appropriateness of healthcare services and apply established criteria for resource utilization.
• Identify and refer members for Health Coaching or case management interventions.
• Educate providers and vendors to streamline processes and improve network relationships.
• Analyze outcomes data to develop strategies for improving provider and member satisfaction.
• Ensure all activities comply with state and federal laws, including HIPAA regulations.

Requirements

• Current State of PA RN licensure or multi-state licensure through the eNLC.
• 3 years of related, progressive clinical experience.
• Working knowledge of regulatory compliance guidelines and medical policies.
• Strong analytical, organizational, and multi-tasking skills.
• Excellent written and verbal communication skills.
• Proficiency in computer software and data analysis.

Nice to have

• Bachelor’s Degree in Nursing.
• Experience in UM/CM/QA or Managed Care.
• Certification in utilization management or a related field.

Culture & Benefits

• Opportunity to work in a fast-paced, professional healthcare environment.
• Focus on ethical practice and high-quality patient care.
• Professional development through ongoing education and provider interaction.
• Commitment to diversity and inclusion in the workplace.