RN Case Manager - Utilization & Care Coordination

Big Future Music Group; Bakersfield, Northern (CA, KY); Hybrid; USD 74,000 - 87,000; Full time

Job summary

Big Future Music Group is seeking an experienced RN Case Manager to support Utilization Management and Customer Service in our California operations. You will review referrals for ambulatory care, elective inpatient services, and equipment using evidence-based criteria and collaborate with Medical Directors and UM leadership to ensure appropriate care.

You will interact with providers, clinic staff, and patients, document decisions, maintain HIPAA compliance, and contribute to a positive team

Qualifications

• Graduate from an accredited school of Nursing.
• Current valid Unrestricted RN license in California.
• Three years acute hospital experience.
• Experience with CMS, Health Plans, MCG, InterQual preferred.
• Excellent written and oral communication skills.
• Computer knowledge required.

Responsibilities

• Review referrals for ambulatory, elective inpatient and equipment per criteria.
• Coordinate UM processes with Health Plans, CMS, InterQual guidelines.
• Apply CMS/Health Plan benefit hierarchy to service requests.
• Document referrals and maintain HIPAA confidentiality.
• Serve as clinical liaison to Medical Director and UM leadership.
• Communicate patient care decisions to providers and patients.
• Identify issues and propose solutions to improve UM processes.
• Attend meetings and participate in training as required.

Skills

Communication skills

Independent decision making

Computer skills

Education

Licensed Registered Nurse (RN) in California

Nursing degree from an accredited school

Job description

Big Future Music Group is seeking an experienced RN Case Manager to support Utilization Management and Customer Service in our California operations. You will review referrals for ambulatory care, elective inpatient services, and equipment using evidence-based criteria and collaborate with Medical Directors and UM leadership to ensure appropriate care.

You will interact with providers, clinic staff, and patients, document decisions, maintain HIPAA compliance, and contribute to a positive team