Job Description:
• Manage and coordinate an assigned caseload of complex, high-acuity, or account-sensitive inpatient cases
• Complete prospective, concurrent, and retrospective clinical reviews for acute inpatient care, rehabilitation, referrals, select outpatient services, and durable medical equipment, as applicable
• Apply approved clinical guidelines and tools to evaluate medical necessity, level of care, covered services, treatment goals, risk factors, and discharge needs
• Review the daily census, prioritize cases, request relevant clinical information, and document decisions, interventions, and outcomes accurately and on time
• Create member-centered short- and long-term care plans with measurable goals, follow-up timeframes, and criteria for transition or closure
• Coordinate with members, families, physicians, facilities, vendors, caregivers, and internal partners to support timely discharge or transfer
• Identify and help resolve gaps in care, barriers to discharge, readmission risk, and service delays
• Educate members about benefits, care options, costs, and community resources
• Serve as a member advocate and liaison within benefit, regulatory, contractual, and program requirements
• Escalate complex cases, quality-of-care concerns, and service delays to managers, medical directors, or Quality partners
• Identify referrals for complex or specialty case management programs and coordinate transitions
• Build relationships with internal teams, providers, customers, and community resources
• Support customer or auditor visits, special projects, peer consultation, and related duties
Requirements:
• Must currently reside in California
• Active, unencumbered California RN licensure
• Minimum of two years of direct clinical RN experience in an inpatient or managed care setting
• Bachelor’s degree in nursing or a related field (preferred)
• Ability to assess complex clinical information, identify barriers, recommend solutions, and make sound decisions
• Strong written and verbal communication, organization, time management, research, analytical, negotiation, and problem-solving skills
• Ability to work independently, manage competing priorities, and collaborate in a fast-paced, matrixed environment
• Proficiency using computers and clinical or case management systems
• Experience in medical management, utilization management, or case management within a health plan or hospital setting
• Knowledge of managed care products, care management strategies, and community, state, and federal resources
• Demonstrated ability to anticipate needs, coordinate services, and build cooperative relationships with diverse internal and external partners
• Must be able to work an 8-hour shift between 8:00 a.m. and 5:00 p.m. PST, Monday-Friday
• Home internet connection must use cable broadband or fiber optic service with at least 10 Mbps download and 5 Mbps upload
Benefits:
• Annual bonus plan eligibility
• Medical, vision, and dental benefits starting on day one
• Well-being and behavioral health programs starting on day one
• 401(k)
• Company-paid life insurance
• Tuition reimbursement
• Minimum of 18 days of paid time off per year
• Paid holidays
• Leaves of absence
• Remote work arrangement
• Cable broadband or fiber optic internet service requirement for home working