Care Manager

Key Submission Requirements

• Licensure: Active Alaska RN license required at time of submittal.
• Experience: Minimum 8 years of clinical nursing experience, with at least 3 years in chart review, risk management, or related quality service.
• Certification: Case Management certification by a recognized body (e.g., NCQA, CCMC) preferred.
• Immunization: Proof of flu vaccine required.
• Timeline & Onboarding:
  • Start date will be no less than 6 weeks after fingerprint cards are received in Juneau for processing.
  • Fingerprint appointment must be scheduled and cards mailed within 2–3 days of offer acceptance to avoid start date delays.

Job Summary

The Utilization Management / Case Management Registered Nurse manages patient progression of care, promotes evidence-based protocols, ensures the appropriateness of clinical interventions, and expedites care delivery for admitted patients. This position oversees discharge planning, evaluates medical necessity and length of stay, and collaborates with multidisciplinary teams to deliver cost-effective, high-quality care.

Core Responsibilities

Utilization Management & Chart Review

• Conduct ongoing reviews of patient records to evaluate medical necessity, appropriateness of hospitalization, length of stay, and quality of care.
• Perform utilization management (UM) and review functions for beneficiary patients admitted to external facilities.
• Review new admissions to assess clinical conditions and assist in developing personalized care plans.
• Obtain and review medical reports and treatment plans requested by payers and regulatory agencies.
• Maintain the Utilization Review Plan in collaboration with UM staff and the Medical Director (or designated provider).

Care Coordination & Discharge Planning

• Direct patient care services to ensure timely and appropriate patient discharge planning (UM/CM/DCP).
• Collaborates with leadership, physicians, and multidisciplinary care teams to ensure healthcare services are appropriate, cost-effective, and aligned with UM/CM/DCP plans.
• Educate patients and their families regarding healthcare benefits and care progression.
• Facilitate educational programs to advise physicians and hospital departments on regulations affecting UM/CM/DCP.

Appeals, Compliance & Quality

• Ensure clinical documentation supports UM functions and communicate with payers within mandatory timeframes.
• Receive and process denial appeal requests, respond to complaints per UM guidelines, and maintain utilization review and appeal logs.
• Communicate review results to claims adjusters, enter billing information, and prepare provider/patient notification letters.
• Perform tumor registry functions and support clinical quality improvement initiatives.

Qualifications & Credentials

• Education: Bachelor's Degree in Nursing (BSN).
• Licensure: Active, unrestricted Registered Nurse (RN) license in the State of Alaska at time of submission.
• Certifications: Case Management certification (NCQA, CCMC, or equivalent) preferred.
• Experience: 8 years of clinical care or nursing experience required, with a minimum of 3 years dedicated to chart review, risk management, or quality service.
• Supervisory Role: Non-supervisory position.

Required Knowledge, Skills & Abilities

• Regulatory & Coding Knowledge: Understanding of medical necessity criteria, level of care reviews, public/private insurance reimbursement, CMS regulations, basic CPT/ICD coding, medical terminology, anatomy, and disease processes.
• Core Competencies: Strong clinical assessment, critical thinking, organizational, and case tracking skills.
• Communication & Collaboration: Excellent written and verbal communication skills; ability to collaborate effectively with providers, interdisciplinary staff, patients, payers, and claims adjusters.