RN, Care Manager, Utilization Management (Full-Time, Remote)

Adventist Health is a faith-based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of more than 38,000 includes employees, physicians, Medical Staff, and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.

Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect. Whether virtual or on campus, Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work. Job Location Details: Remote position but must live near Glendale, CA, Roseville, CA or Portland, OR Job Summary: Plays a critical role in ensuring that patients receive high-quality care while efficiently utilizing medical resources. Reviews patient medical records, assessing the appropriateness and necessity of proposed treatments, and collaborating with healthcare providers and insurance companies to ensure a seamless care experience and the practicing of financial stewardship and denial prevention. Focuses on maximizing patient outcomes and optimizing resource allocation. Utilizes exceptional clinical knowledge, excellent communication skills, and the ability to thrive in a fast-paced and ever-changing healthcare environment.

Completes clinical reviews of acute medical patients using the Optum/Inter Qual tool to determine if the patient is in the right acute setting, receiving the right acute services, during the appropriate length of stay. Participates in annual Optum/Inter Qual training required. Takes the required annual Optum/Inter Qual Interrater Reliability (IRR) test with a minimum passing score as defined in the yearly departmental goals. Meets weekly productivity metrics within 90 days of completing orientation and maintains on a weekly basis as defined in the yearly departmental goals. Meets quality audit metrics within 90 days of completing orientation and maintained on the audit cadence set within the department as defined in the yearly departmental goals. Completes all required departmental education assigned with timeliness and accuracy. Follows all departmental workflows in communication variances to the on-site care management teams when appropriate. Reviews and analyzes medical records to assess the necessity and appropriateness of treatments and interventions. Collaborates with healthcare professionals to develop and implement comprehensive patient care plans. Facilitates communication between the patient, healthcare team, insurance providers, and other stakeholders to ensure a coordinated and efficient care process. Stays up to date with the latest healthcare regulations, insurance guidelines, and evidence-based practices to ensure the delivery of optimal healthcare services. Performs other job-related duties as assigned.