Registered Nursing (RN) Case Manager II, Utilization Management, Full-Time/Days

Long Beach Medical Center
Full Time
Day Job
Job Listing: 
Case Management - Utilization

Purpose Statement / Position Summary

The case manager is a licensed professional who assesses the ongoing care andappropriate discharge plan of a specific caseload of patients through the continuum of care.The case manager collaborates with members of the health care team to assure effective, efficient, and appropriate care and outcomes. Fiscal responsibilities include management of utilization, providing clinical information to payers and assuring appropriate reimbursement.

Case Management

The case manager independently manages a specific case load of patients as identified by the Utilization Management Department.The case manager analyzes patient information and assesses each patient�s functional status and decision making ability in relation to the continuum of care and discharge needs.The case manager collaborates with the health care team in planning and facilitating the achievement of expected outcomes for patients.Each treatment plan is evaluated for appropriate quality outcomes and utilization of resources.

Utilization Management

The case manager works collaboratively and proactively with payors in managing patient resources.The case manager assures the hospital receives appropriate reimbursement through collaboration with the health care team and provides timely clinical review, as well as, retroactive review for unbilled accounts.The case manager utilizes the billing system to analyze charges vs. reimbursement and contract information.This information is used to structure the health care team toward effective utilization of resources.The case manager incorporates knowledge of medical necessity, CareLine protocols, and MAPs to evaluate for appropriateness of admissions, continued stay, and discharges.The case manager refers cases, as appropriate, for review to the Utilization Management Committee and other Medical Staff Committees as needed


Minimum Requirements / Work Experience   

  • This position requires strong verbal and written communication skills with the ability to communicate well with people from diverse socioeconomic backgrounds.The case manager is knowledgeable of criteria for medical necessity for each level of care through the continuum of care.A knowledge of reimbursement related to Medicare, Medi-Cal, Capitation, and Managed Care is required.
  • Three years experience in clinical field of expertise with two years experience in an acute setting is preferred.
  • Current California RN required.
  • Bachelors degree in health related field.
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