IP Case Manager/Utilization Review

Job Purpose & Position Overview This position is responsible for providing Utilization Review and Case Management services for patients in the Twelve Clans Unity Hospital and patients referred to the private sector through the WCHS Purchase Referred Care Program. Specific Job Duties/Responsibilities: Demonstrates the WCHS core Mission, Vision and Values Responsible for conducting timely reviews of all request for services required to meet medical necessity criteria to include reviewing pre-certification for outpatient and inpatient services, applying criteria to inpatient admissions and performing concurrent review functions, identifying discharge and case management needs. Provides clinical oversight and direction for all PRC Catastrophic Health Emergency Fund cases submitted for reimbursement. Evaluates clinical information submitted by providers against InterQual criteria and Medicare admission and discharge criteria. Utilizes clinical information to determine if criteria for medical necessity are met. Utilizes professional judgement to determine if additional information is required, then follows through to obtain additional information prior to making a decision. Documents all pertinent case information and dispositions for approvals and denials. Refers all cases failing to meet InterQual criteria to Clinical Director for review and final determination. Communicates with providers to initiate/coordinate outpatient services/discharge planning needs for patients. Acts as a liaison to assure services are being provided to patients referred to private sector hospital for specialty referral care. Performs other duties as assigned. Makes decisions in matters of significance Required Qualifications/Skills: Associate's Degree required; Bachelor's Degree preferred and one-year proven experience as a Case Manager or Utilization Review or combination of education and applicable experience Must possess a valid full and unrestricted Professional license as a Registered Nurse in any state of the United States of America, the Commonwealth of Puerto Rico, or a territory of the United States. Must have excellent communication skills and can relate easily to both patient and providers. Must have an understanding of the InterQual review criteria. Training Requirements: N/A Physical Requirements: Normal to light office work which includes the ability to lift up to 30 lbs. Regularly required to walk, stand, and sit for extended periods of time and use hands to operate computer keyboard, phone, and various office equipment. Cognitive Requirements: Reading, writing, calculating Above average social interaction skills Reasoning/Analysis Works with minimal to no supervision Language Requirements: Must possess the ability to read, write, and speak the English language fluently. Must be able to continually and effectively employ professional verbal and written communications skills. Certificates, Licenses & Registrations: All applicants will comply with 45 CFR 1301, Subpart D, Section 1301.31, C and D, which require all prospective employees to sign a declaration prior to employment regarding all arrests and convictions of child abuse or violent felonies and to comply with PL 101-630 and PL 101-637 regarding criminal records check. Please note the position description duties, responsibilities, and activities may change at any time with or without notice. WCHS is an equal opportunity employer. All applicants must comply with 45 CFR 1301, Subpart D, Section 1301.31 C and D, which require all prospective employees to sign a declaration prior to employment regarding all arrests and convictions of child abuse or violent felonies and comply with PL 101-630 and PL 101-637 regarding criminal records check. As provided by Federal Law, all qualified Native American and Veteran applicants shall receive preference over Non-Native American applicants. In the absence of qualified Native American applicants, consideration will be given to all other applicants without regard to race, color, religion, gender, gender orientation/identity, national origin, age, marital status, veteran status, genetic information, disability or any other reason prohibited by law in provision of employment opportunities and benefits. WCHS participates in E-Verify.

Created: 2026-03-04