RN - Case Manager - AS Utilization Management - Full Time - 8 Hour - Days

About the role

The inpatient case manager serves as a patient advocate for appropriate utilization of resources. This role involves applying the process of assessment, planning, implementation, monitoring, evaluation, and coordination of care to meet the patient’s health care needs through hospitalization and transition back to the community, in coordination with the interdisciplinary health team. The RN Case Manager functions within the full scope of nursing practice with a specialized focus on care coordination, compliance, transition management, education, and utilization management.

Responsibilities

• Assess, plan, implement, monitor, and evaluate patient care during hospitalization and transition back to the community.
• Coordinate care in collaboration with the interdisciplinary health team.
• Apply specialized knowledge of Medicare, Medi-Cal, and commercial coverage guidelines to ensure appropriate utilization of resources.
• Understand and navigate reimbursement models such as ACOs, DRGs, and Full Risk.
• Manage patient levels of care (Inpatient, Observation, Outpatient) according to criteria, rules, and regulations.
• Provide education and support for patients and families managing chronic/progressive disease states (e.g., CHF, COPD, Diabetes, End Stage Renal Disease).
• Collaborate with Social Workers and Palliative Care Resources to address patient needs.
• Plan, organize, prioritize, and manage time effectively in a multidisciplinary team setting.
• Demonstrate leadership by delegating tasks, providing guidance, and holding staff accountable.
• Utilize computer programs such as EPIC, Allscripts, InterQual, and Microsoft Outlook.

Requirements

• Bachelor's Degree from an accredited School of Nursing (Required).
• 3 years of Nursing experience in Medical/Surgical or Critical Care (Preferred).
• 2 years of Care Coordination or Case Management experience (Preferred) or equivalent work experience.

Qualifications

• Active RN (Registered Nursing) license from the California Board of Nursing (Required).
• BLS (Basic Life Support) certification from the American Heart Association (Required).
• ACM (Accredited Case Manager) from ACMA or CCM (Certified Case Manager) from CCMC (Strongly Preferred).

Skills

• Strong written and verbal communication skills.
• Ability to motivate and lead teams effectively.
• In-depth knowledge of Medicare, Medi-Cal, and commercial insurance guidelines.
• Understanding of common diagnoses, procedures, and their impact on patients and families.
• Knowledge of individual and family development across the lifespan, including cultural and spiritual influences on healthcare.
• Familiarity with reimbursement models and their impact on care delivery and patient management.
• Strong understanding of geriatrics and chronic/progressive disease states.
• Ability to work independently and collaboratively within a multidisciplinary team.
• Effective problem-solving and conflict resolution skills.
• Respectful and creative approach to working with diverse clients.
• Proficiency in computer programs such as EPIC, Allscripts, InterQual, and Microsoft Outlook.

Schedule

Fixed rotating schedule:

• Week 1: Sunday – Wednesday
• Week 2: Sunday – Thursday

Shift: 08:00 – 16:30

Scheduled Weekly Hours: 36

Pay

Hourly pay range: $89.23 – $121.58. Offer amounts are based on demonstrated/relevant experience and/or licensure. Pay may be adjusted to the local market if hired outside of the Bay Area.