PACE Resource Management RN: Care Coordination

San Ysidro Health; San Diego (CA); On-site; USD 90,000 - 130,000; Full time

Job summary

San Ysidro Health is seeking a PACE Resource Management RN to oversee non-acute resource management and care coordination for PACE participants. The role reviews claims, assesses medical necessity, and ensures care plans are aligned with InterQual criteria and IDT decisions.

The RN will work with the Medical Director Resource Management and PACE CMO to implement projects that improve outcomes and reduce costs, including post-acute and homecare planning and ensuring timely authorizations and

Qualifications

• Minimum of 3 years RN experience in outpatient/hospital/PACE/resource utilization.
• Knowledge of PACE regulations and care coordination processes.
• Experience with utilization management and risk assessment.
• Strong analytical, communication, and collaboration skills.

Responsibilities

• Performs retrospective and prospective reviews to assess appropriateness and medical necessity using InterQual.
• Reviews medication use, diagnostics, referrals, DME, and care hours for costs and quality.
• Collaborates with IDT and PACE CMO to develop and implement care plans.
• Coordinates authorizations and facilitates timely communication with providers.
• Monitors KPI indicators for resource management and reports highest utilization cases.

Skills

RN experience

Care coordination

InterQual knowledge

Analytical skills

Education

Graduate of an accredited registered nursing program

ASN/BSN preferred

Tools

EPIC EMR

InterQual

QuickCap

Job description

San Ysidro Health is seeking a PACE Resource Management RN to oversee non-acute resource management and care coordination for PACE participants. The role reviews claims, assesses medical necessity, and ensures care plans are aligned with InterQual criteria and IDT decisions.

The RN will work with the Medical Director Resource Management and PACE CMO to implement projects that improve outcomes and reduce costs, including post-acute and homecare planning and ensuring timely authorizations and