Case Management Registered Nurse (RN)

Quick Facts

• Role: Case Management Registered Nurse (RN)

Description

Conduct preauthorization, concurrent, and retrospective utilization management reviews using department criteria to confirm medical necessity and the appropriate level of care for ambulatory, acute, and post-acute patients. Coordinate utilization management, resource management, discharge planning, post-acute care referrals, and care facilitation to support patient wellness, improved outcomes, and efficient use of health services among patients with complex health needs.

Responsibilities

• Perform utilization management reviews (preauthorization, concurrent, retrospective)

• Coordinate utilization management and resource management

• Support discharge planning and post-acute care referrals

• Facilitate care to ensure appropriate care placement and positive patient experience

• Communicate and collaborate effectively with patients/families/caretakers, physicians, nurses, and ancillary partners

Requirements

• Graduate of an accredited school of nursing

• RN — Registered Nurse of California

• BLS — Basic Life Support Healthcare Provider

• CCM — Certified Case Manager (certification may be required; time to acquire may depend on qualifications)

• 2 years recent relevant experience

• Comprehensive knowledge of utilization review, levels of care, and observation status

• Knowledge of laws, regulations, and professional standards affecting case management (e.g., CMS grouper, Title 22, CHA Consent Manual, CDPH, The Joint Commission)

• Verbal and written communication skills, including negotiation and interpersonal skills

• Time management skills for a high-volume, rapidly changing environment

• Intermediate computer skills