111693 - (RN) Inpatient Utilization RN Case Manager
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#111693 (RN) Inpatient Utilization RN Case ManagerFiling Deadline: Mon 9/27/2021
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UCSD Layoff from Career Appointment: Apply by 09/16/2021 for consideration with preference for rehire. All layoff applicants should contact their Employment Advisor.
Special Selection Applicants: Apply by 09/27/2021. Eligible Special Selection clients should contact their Disability Counselor for assistance.
UC San Diego Health is a Magnet designated organization, which is a prestigious recognition that applies to only 10% of all U.S. hospitals. Magnet is the "gold standard" for nursing excellence and is based on strengths in five key areas, which include transformational leadership, structural empowerment, exemplary professional practice, new knowledge, innovation and improvements and empirical outcomes. UC San Diego Health has held its Magnet status since 2011.
Reporting to the Medical Group Managed Care UM Manager, the Case Manager is responsible for utilization management, patient care planning, and discharge planning. Interprets medical policy and benefit plan descriptions for covered and medically appropriate service authorization decisions, referencing available resources and guidelines as appropriate. Organizes and reviews referral cases with Medical Director as needed. Assists in monitoring referral patterns and makes recommendations to help improve access and quality of care.
Reviews appropriateness of the primary and specialty care utilization process and acts as a clinical liaison between various oversight agencies and Managed Care. The case manager will be accountable for working with hospital and clinic patient care teams to assess and identify individual patient's needs, ensure timely initiation of care plans, and monitor patient progress relative to those plans. Will work closely with the interdisciplinary team, physicians, vendors, and health plans to enhance communication and improve quality and timeliness of care.
Must be a graduate from an accredited school of Nursing.
RN license issued by the State of California.
Minimum (2) years of recent case management, utilization review, and/or care coordinator experience, preferably in a Managed Care setting.
Proficiency in Information Systems and computer programs such as Word and Excel.
- BSN or Master's Degree.
- ACM and/or CCM certificate.
- Managed Care UM experience.
- Strong understanding of inpatient acute and Skilled Nursing Facility medical necessity and level of care NCQA guidelines (MCG or InterQual).
- Three (3.5) and half years of acute care setting or clinical RN experience.
- Two (2+) or more years of utilization management experience.
- Two (2+) or more years of case management experience.
- Midas, ECIN, InterQual and Milliman experience.
- Recent Population Health/Managed Care experience.
- The location of this position is not on-site at hospitals but at the Managed Care office in La Jolla. This position may be able to work at a hybrid model between the Managed Care office and remotely from home.
- Must be able to work various hours and locations based on business needs.
- Employment is subject to a criminal background check and pre-employment physical.
Job offer is contingent on successful engagement in the UC COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).
UC San Diego Health is the only academic health system in the San Diego region, providing leading-edge care in patient care, biomedical research, education, and community service. Our facilities include two university hospitals, a National Cancer Institute-designated Comprehensive Cancer Center, Shiley Eye Institute, Sulpizio Cardiovascular Center, and several outpatient clinics. UC San Diego Medical Center in Hillcrest is a designated Level I Trauma Center and has the only Burn Center in the county. We invite you to join our dynamic team!
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