Regional Care Manager; Midwest or Eastern Region

Regional Care Manager (Midwest or Eastern Region)

We are on a path to better healthcare and invite you to join a mission‑driven organization focused on underserved patients.

• Make a difference every day in the lives of the underserved
• Join a people‑first culture that values compassion, collaboration, and innovation
• Enjoy excellent career growth opportunities

The Regional Care Manager (RCM) is responsible for utilization review, care coordination, and daily care management across multiple sites and states. The RCM handles pre‑certification for urgent, scheduled, and routine procedures while applying Inter Qual criteria and maintaining compliance with departmental policies. The RCM collaborates with medical directors, site leadership, and care management teams to enhance best practices and regulatory compliance.

The role requires frequent communication with clients, providers, and site personnel, as well as travel for meetings, training, and support as needed.

• Conduct clinical reviews of off‑site observation, outpatient, and acute care using Inter Qual criteria.
• Review and document concurrent clinical information in ERMA Care Management and Track Via systems, ensuring compliance with claims and medical review procedures.
• Manage pre‑certification referrals for urgent, scheduled, and routine services including physician visits, procedures, imaging, and specialty care.
• Coordinate care with medical directors, site staff, and operations to ensure accuracy in utilization data and billing processes.
• Collaborate with the Care Management team to develop best practices, core competencies, and regulatory compliance procedures.

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 Inter Qual evidence‑based guideline tools
• 3+ years of hands‑on clinical experience
• Computer proficiency with MS Word, Excel, and Power Point

Licenses/Certifications

• Current Nursing Licensure
• Case Management Certification preferred

We celebrate diversity and are committed to creating an inclusive environment for all employees.

If you are excited about a role but your experience doesn’t seem to align perfectly with every element of the job description, we encourage you to apply. You may be just the right candidate for this, or one of our many other roles.