RN Care Manager II — Care Coordination & Utilization Review

Hoag Health System; Irvine (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

Hoag Memorial Hospital Presbyterian in Irvine, CA seeks a Care Manager (RN) to coordinate patient discharge planning, assess clinical needs, and align with payer requirements through the continuum of care, including post-acute services.

The role emphasizes reviewing assessments, validating admission status and level of care, documenting issues, and communicating with physicians to secure appropriate authorizations; experience with Interqual or Millennium guidelines is required.

Qualifications

• Five years of clinical experience in an acute healthcare system environment.
• Experience in Interqual or Millennium Guidelines required.
• One year of experience in utilization review required.
• Experience with healthcare database systems.
• Care Manager II (RN) – Bachelor’s or Master’s degree in Nursing (BSN/MSN).

Responsibilities

• The Care Manager coordinates patients’ needs through the continuum of care, including post-acute care and discharge planning.
• Reviews clinician assessments and patient financial, family and psychosocial factors to justify hospitalization for clinical reviews.
• Reviews records to assess admission status, level of care, payer source, and UR contracts to validate billing.
• Documents pertinent patient issues, contacts and discharge plans on medical reviews.
• Communicates with physicians and medical offices to confirm insurance authorizations are in place and assists with appeals/denials as needed.

Job description

Hoag Memorial Hospital Presbyterian in Irvine, CA seeks a Care Manager (RN) to coordinate patient discharge planning, assess clinical needs, and align with payer requirements through the continuum of care, including post-acute services.

The role emphasizes reviewing assessments, validating admission status and level of care, documenting issues, and communicating with physicians to secure appropriate authorizations; experience with Interqual or Millennium guidelines is required.