Case Manager EX - Utilization Management

The Case Manager EX - Utilization Management role is offered by a partner company managing all applications and next steps. This position supports high-quality patient care by ensuring effective utilization of healthcare resources across a leading academic health system. Key responsibilities include:

1. Evaluate clinical services and coordinate care processes.
2. Help improve outcomes through data-driven utilization management practices.
3. Collaborate with physicians, clinical teams, and operational stakeholders to promote appropriate care delivery.
4. Identify utilization trends, support documentation quality, and reduce barriers within the patient care journey.

Requirements

• Experienced nursing professional with a strong understanding of clinical care, utilization management practices, and healthcare compliance requirements.
• Current Registered Nurse (RN) license required.
• Bachelor of Science in Nursing (BSN) required for external candidates.
• Minimum of 5 years of clinical experience and at least 1 year of case management experience preferred.
• Strong understanding of patient acuity levels and clinical documentation requirements.
• Knowledge of utilization management practices and healthcare regulatory standards, including Joint Commission, CMS, CDPH, and CCS requirements.
• Excellent written and verbal communication skills in English.
• Strong customer service skills and ability to collaborate effectively with multidisciplinary teams.
• Proficiency with computer systems and software, including Microsoft Office applications such as Word, Excel, PowerPoint, and Outlook.
• Ability to manage multiple projects and maintain productivity in a fast-paced healthcare environment.
• Strong analytical, organizational, and problem-solving skills.
• Able to establish and maintain effective professional relationships across healthcare departments.
• Familiarity with California Children’s Services (CCS) authorization processes is preferred.
• CCM or ACM certification is preferred.
• Bilingual skills are a plus.

Benefits

• Comprehensive benefits package including medical insurance coverage, retirement savings plans, paid sick leave and vacation time, employee discounts, and wellness programs.
• Opportunities to work within a leading academic healthcare environment.
• Professional development opportunities and continued learning support.
• A collaborative workplace focused on patient care, innovation, research, and education.