Case Manager II

Sutter Health•Rancho Cordova, CA

1d•$82 - $115

About The Position

Conducts concurrent utilization management reviews for hospitalized and acute care patients using established clinical criteria and evidence-based guidelines to evaluate medical necessity, appropriateness of care, continued stay, and level-of-care requirements. Assesses patients’ clinical status and progression throughout hospitalization to support timely, appropriate, and effective utilization of healthcare services. Collaborates with physicians, hospital care teams, case management, health plans, post-acute providers, and other stakeholders to identify barriers to progression of care, support timely transitions, and facilitate appropriate discharge planning and post-acute services. Escalates cases requiring additional clinical review or physician involvement in accordance with regulatory, health plan, and organizational requirements. Prioritizes concurrent reviews according to clinical urgency, required review intervals, regulatory and health plan turnaround times, and organizational standards. Monitors continued-stay reviews, length of stay, level of care, documentation needs, and discharge readiness to promote timely clinical decision-making and reduce avoidable delays in care. Maintains accurate and timely documentation supporting medical necessity determinations, provider and health plan communications, regulatory compliance, and audit readiness. Ensures adherence to applicable CMS, DMHC, health plan, and organizational requirements for utilization management, physician review, notifications, and coordination of care. Promotes patient-centered care, quality outcomes, safe transitions, and responsible use of healthcare resources while supporting regulatory compliance, patient safety, and organizational stewardship for patients with complex acute and post-acute care needs.

Requirements

Graduate of an accredited school of nursing.
California Registered Nurse (RN) licensure.
Two years of experience in acute care case management or health plan case management/utilization management.
Broad knowledge of healthcare 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 CMS, DMHC, and NCQA requirements.
Broad knowledge of outpatient, acute, and post-acute levels of care and associated regulatory compliance requirements.
Ability to communicate effectively and promote cooperation and collaboration among patients, families, caretakers, physicians, nurses, and ancillary partners.
Ability to work independently and exercise sound judgment in interactions with physicians, payers, patients, and families.
Commitment to service excellence and quality patient care and experience.
Verbal and written communication skills.
Interpersonal communication and negotiation skills.
Time management skills to organize work in a high-volume environment with rapidly changing priorities.
Intermediate computer skills.
Ability to promote teamwork and function effectively in teams.
Ability to interact effectively with internal and external constituents using collaboration and customer service skills.

Responsibilities

Conduct concurrent utilization management reviews for hospitalized and acute care patients using clinical criteria and evidence-based guidelines.
Evaluate medical necessity, appropriateness of care, continued stay, and level-of-care requirements.
Assess patients’ clinical status and progression of care throughout hospitalization.
Collaborate with physicians, hospital care teams, case management, health plans, post-acute providers, and other stakeholders to identify barriers and facilitate transitions, discharge planning, and post-acute services.
Escalate cases requiring additional clinical review or physician involvement in accordance with applicable requirements.
Prioritize concurrent reviews based on clinical urgency, review intervals, turnaround times, and organizational standards.
Monitor continued-stay reviews, length of stay, level of care, documentation needs, and discharge readiness.
Maintain accurate and timely documentation supporting determinations, communications, compliance, and audit readiness.
Ensure adherence to applicable CMS, DMHC, health plan, and organizational requirements related to utilization management, physician review, notifications, and coordination of care.
Promote patient-centered care, quality outcomes, safe transitions, patient safety, and responsible utilization of healthcare resources.