Care Manager I (RN) - Per Diem : Irvine Care Management

Hoag•Irvine, CA

About The Position

The Care Manager (RN) for Utilization Review is responsible for evaluating inpatient admissions and ongoing hospital stays for medical necessity, appropriate level of care, and regulatory compliance. This role collaborates with physicians, physician advisors, coding, and interdisciplinary teams to ensure accurate patient status determinations and documentation that supports reimbursement and quality outcomes. The Care Manager (RN) coordinate patients’ needs through the continuum of care which can include from pre-admission through post discharge plans. This role works in collaboration with the physicians, nurses, clinical staff, and community agencies to identify and arrange for appropriate care. Reviews clinician assessments and patients’ financial, family and psychosocial support to develop comprehensive care and/or discharge plans. May focus more heavily on a specific aspect of Care Management like discharge planning, utilization review, and/or providing psychosocial support. May review records to assess for appropriate admission status, level of care, payer source, and UR contracts to validate billing. May provide psychodynamic intervention and crisis counseling to support patients and families. Educates patients and families on their healthcare options and connects them with resources. Documents pertinent patient issues, contacts and plans on the medical records. Is a mandated reporter for elder, child, and spousal abuse. The Community Care role specifically provides Care Management support to high-risk, homeless and mental health population. Performs other duties as assigned.

Requirements

Bachelor’s degree in Nursing (BSN) required.
Registered Nurse (RN) license.

Nice To Haves

One year of experience in an acute health care setting preferred.
Experience and/or knowledge of Interqual/Milliman guidelines (MCG) clinical criteria.
Experience with CMS regulations and guidelines, including the Two-Midnight Rule, MOON requirements, Conditions of Participation.
Maintains professional communication with medical staff and co-workers.
Demonstrates strong clinical judgement, attention to detail, and regulatory awareness.
Familiarity with denials management and appeal process.
Experience in utilization review, quality management, or clinical documentation improvement.
Knowledge of payer authorization processes and revenue cycle workflows.

Responsibilities

Evaluating inpatient admissions and ongoing hospital stays for medical necessity, appropriate level of care, and regulatory compliance.
Collaborating with physicians, physician advisors, coding, and interdisciplinary teams to ensure accurate patient status determinations and documentation that supports reimbursement and quality outcomes.
Coordinating patients’ needs through the continuum of care, from pre-admission through post-discharge plans.
Working in collaboration with physicians, nurses, clinical staff, and community agencies to identify and arrange for appropriate care.
Reviewing clinician assessments and patients’ financial, family and psychosocial support to develop comprehensive care and/or discharge plans.
Assessing for appropriate admission status, level of care, payer source, and UR contracts to validate billing.
Providing psychodynamic intervention and crisis counseling to support patients and families.
Educating patients and families on their healthcare options and connecting them with resources.
Documenting pertinent patient issues, contacts and plans on the medical records.
Acting as a mandated reporter for elder, child, and spousal abuse.
Providing Care Management support to high-risk, homeless and mental health population (Community Care role).
Performing other duties as assigned.