Care Manager, Registered Nurse

About the role

Responsible for Care Coordination and Care Transitions Planning throughout the acute care patient experience. Works in collaboration with the Physician, Utilization Manager, Medical Social Worker and bedside RN to assure the timely progression and transition of patients to the appropriate level of care to prevent unnecessary admissions or readmissions. The Care Management process encompasses communication and facilitates care across the continuum through effective resource coordination.

Responsibilities

• Achieve optimal health, access to care, and appropriate utilization of resources balanced with patients’ self‑determination while coordinating in a timely and integrated fashion.
• Collaborate with patients, families, physicians, the interdisciplinary team, nursing management, quality, ancillary services, third‑party payers and review agencies, claims and finance departments, Medical Directors, contracted providers, and community resources.
• If assigned to the Emergency Department, address complex clinical and social situations efficiently to avoid unnecessary admissions.

Requirements

• Education: Graduate of an accredited school of nursing.
• Certification & Licensure: RN‑Registered Nurse of California (upon hire).
• Typical Experience: 2 years of experience in acute care case management or health plan case management/utilization management.

Skills

• Broad knowledge base of health care delivery and case management within a managed care environment.
• Comprehensive knowledge of Utilization Review, levels of care, and observation status.
• Awareness of healthcare reimbursement systems: HMO, PPO, PPS, CMS, value‑based reimbursement models, and alternative payment systems preferred.
• Working knowledge of laws, regulations, and professional standards affecting case management practice in an integrated delivery system: including but not limited to CMS, Title 22, CHA Consent Manual, CDPH and TJC.
• Broad knowledge base of post‑acute levels of care and associated regulatory compliance requirements.
• General understanding of coding