Case Management Utilization Nurse

CARIN Alliance; Baldwin Park (CA); On-site; USD 85,000 - 110,000; Full time

Job summary

CARIN Alliance in Baldwin Park, CA seeks a detailed-oriented professional to oversee utilization review and care coordination across care settings. You will assess medical necessity, determine appropriate levels of care, and support discharge planning to ensure continuity of care.

The role requires collaboration with physicians and multidisciplinary teams to optimize patient outcomes and regulatory compliance, coordinating transfers and post-hospital resources as needed.

Qualifications

• Experience in utilization review and determining medical necessity.
• Ability to develop and coordinate care plans to support safe discharge.
• Knowledge of health plan requirements and regulatory criteria.

Responsibilities

• Conduct utilization review and evaluate requests for medical necessity.
• Develop and coordinate care plans to support safe, timely discharge.
• Recommend appropriate levels of care based on clinical and regulatory criteria.
• Coordinate patient transfers, authorizations, and required documentation.
• Connect patients with post-hospital resources and follow-up supports.
• Ensure compliance with applicable regulations and health plan requirements.
• Collaborate to maintain seamless communication across care settings.

Skills

Utilization review

Care coordination

Discharge planning

Regulatory compliance

Job description

Role Summary Coordinate utilization review, care planning, and safe discharge for patients across care settings. Partner with physicians and multidisciplinary teams to assess medical necessity, determine the most appropriate level of care, and support continuity of care.

Role Summary Coordinate utilization review, care planning, and safe discharge for patients across care settings. Partner with physicians and multidisciplinary teams to assess medical necessity, determine the most appropriate level of care, and support continuity of care.

Key Duties

• Conduct utilization review and evaluate requests for medical necessity.
• Develop and coordinate care plans to support safe, timely discharge.
• Recommend appropriate levels of care based on clinical and regulatory criteria.
• Coordinate patient transfers, authorizations, and required documentation.
• Connect patients with post-hospital resources and follow-up supports.
• Ensure compliance with applicable regulations and health plan requirements.
• Collaborate to maintain seamless communication across care settings.