Case Manager II

Quick Facts

• Role: Case Manager II
• Focus: Concurrent utilization management reviews for hospitalized and acute care patients
• Experience: 2 years required
• License: RN (California)

Description

Conducts concurrent utilization management reviews for hospitalized and acute care patients using established clinical criteria and evidence-based guidelines to evaluate medical necessity, appropriateness of care, continued stay, and level-of-care requirements. Assesses patient clinical status throughout hospitalization to support timely, appropriate, and effective utilization of healthcare services. Collaborates with physicians, hospital care teams, health plans, and post-acute providers, escalates cases for additional review as needed, and maintains accurate, compliant documentation.

Responsibilities

• Perform utilization review for medical necessity, appropriateness of care, continued stay, and level of care
• Monitor clinical progression, length of stay, level of care, documentation needs, and discharge readiness
• Prioritize concurrent reviews based on clinical urgency and required review intervals
• Identify barriers to progression of care and support timely transitions and discharge planning
• Escalate cases requiring additional clinical review or physician involvement
• Maintain accurate, timely documentation for medical necessity determinations, communication, compliance, and audit readiness
• Ensure adherence to CMS, DMHC, health plan, and organizational utilization management and notification requirements

Requirements

• RN-Registered Nurse of California
• Graduate of an accredited school of nursing
• 2 years of experience in acute care case management or health plan case management/utilization management
• Comprehensive knowledge of Utilization Review, levels of care, and observation status
• Working knowledge of applicable laws, regulations, and professional standards (including CMS Grouper, DMHC, and NCQA)
• Ability to communicate and collaborate with patients/families/caretakers, physicians, nurses, and ancillary partners
• Ability to work independently and exercise sound judgment with physicians, payers, and patients/families
• Verbal and written communication skills; interpersonal communication and negotiation skills
• Time management skills for a high-volume environment with rapidly changing priorities
• Intermediate computer skills

Benefits

Eligible positions include a comprehensive benefits package.