Case Manager II, Registered Nurse

Sutter Health • San Francisco, CA

23d • $87 - $114

About The Position

Conducts preauthorization, concurrent, and retrospective utilization management review using the department’s accepted criteria for ambulatory, acute, and post-acute patients to confirm medical necessity is met and at the appropriate level of care. Coordinates the utilization management, resource management, discharge planning, post-acute care referrals and care facilitation. Strives to promote patient wellness, improved care outcomes, and efficient utilization of health services among a patient population with complex health needs.

Requirements

• Associate Degree in Nursing
• Graduate of an accredited school of nursing
• RN-Registered Nurse of California
• CCM - Certified Case Manager (certification may be required by entity and time to acquire within 2 years of hire)
• 2 years recent relevant experience
• A broad knowledge base of health care delivery and case management within a managed care environment.
• Comprehensive knowledge of Utilization Review, levels of care, and observation status.
• Working knowledge of laws, regulations and professional standards affecting case management practice in an integrated delivery system: including but not limited to: Centers for Medicare and Medicaid Services (GR) Grouper (CMS), Department of Managed Health Care, National Committee for Quality Assurance (NCQA).
• A broad knowledge base of outpatient, acute, and post-acute levels of care and associated regulatory compliance requirements.
• Must be able to effectively communicate with and promote cooperation and collaboration between individuals including patients/families/caretakers, physicians, nurses and other ancillary partners.
• Ability to work independently and exercise sound judgment in interactions with physicians, payers, and patients and their families.
• Demonstrates commitment to service excellence in all patients, family, and employee interactions and in performing all job responsibilities.
• Functions in a manner to promote quality patient care and assure a positive patient experience.
• Verbal and written communication skills.
• Interpersonal communication and negotiation skills.
• Must have time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities.
• Intermediate computer skills.
• Ability to promote teamwork and to effectively function in teams.
• Ability to interact effectively with key internal and external constituents using collaboration, and customer service skills that promote excellence in the patient experience.

Responsibilities

• Conducts preauthorization, concurrent, and retrospective utilization management review
• Coordinates the utilization management, resource management, discharge planning, post-acute care referrals and care facilitation.
• Promotes patient wellness, improved care outcomes, and efficient utilization of health services

What This Job Offers

• Career Level: Mid Level
• Education Level: Associate degree