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Case Management & Concurrent Review Nurse

Company: CareNational
Location: Orange
Posted on: February 14, 2020

Job Description:

Case Management & Concurrent Review Nurse (RN) Managed Care

Orange, CA

*** This Full Time, Benefits Available, CONTRACT-TO-HIRE position is expected to convert to a Permanent / Direct Hire after a few months! ***

Case & Utilization Management Nurse Job Summary:



  • As a member of the medical management team, the Case Management & Utilization Management RN plays an integral part in the coordination of care assessing the members condition and providing them the necessary resources, options, and coordination for a healthy care outcome.

  • Effectively manage an average census of 20-25 patients at any given time.
  • Responsible for coordination of daily inpatient services including assessments, treatment planning, monitoring, evaluation, documentation and discharge planning functions.
  • Interacts with the Medical Directors and hospitalists on a daily basis to determine necessity of continued stay.
  • Ensures appropriate level of care through comprehensive concurrent review for medical necessity of outpatient and inpatient care, as well as the utilization of ancillary services, following evaluation of medical guidelines and benefit determination.
  • The Nurse acts as an advocate for members and their families linking them to other members of the care team to help them gain knowledge of their disease process and to identify community resources for continued growth toward a maximum level of independence.


    Case & Utilization Management Nurse Background Profile:



    • Current unrestricted state Registered Nurse (R.N.) license.
    • Bachelor of Science in Nursing (BSN) or related field is a plus.
    • At least 2 years acute care clinical nursing experience; higher acuity settings (ER, CCU, ICU, OR, etc) preferred.
    • Requires 4 years of concurrent review and 2 years of case management experience.
    • Roughly 3 years with a managed care organization (Health Plan/ HMO/IPA/Medical Group/TPA/MSO, etc).
    • Knowledge of guidelines for Medicaid/Medicare and related state programs is required.
    • Knowledge of InterQual or MCG/Milliman criteria and other guidelines for medical necessity, setting and level of care, and concurrent patient management.
    • Strong computer skills to include Microsoft Word, Excel, database use, and basic data entry.
    • Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts.
    • Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.


      #CLINICAL

      #CareOne

Keywords: CareNational, Orange , Case Management & Concurrent Review Nurse, Executive , Orange, California

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