RN, Health Plan Care Manager

Adventist Health; Lincoln (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

Adventist Health Roseville in California is seeking a Registered Nurse (RN) with preferred BSN and CCM eligibility to lead and evaluate cavitation care management service lines. The role focuses on whole-person care, inpatient and outpatient coordination, and cost-effective care planning within a faith-based, nonprofit health system.

The position emphasizes collaboration with physicians, care teams, and analytics to optimize patient flow, quality, and discharge planning while adhering to medical

Qualifications

• Bachelor's Degree in Nursing (BSN) preferred.
• Nursing experience preferred.
• Certified Case Manager (CCM) preferred.
• Registered Nurse (RN) licensure required.

Responsibilities

• Partner with internal and external physician advisors, claims, data management and analytics to safeguard member population outcomes.
• Collaborate with physicians, staff and service line leadership on quality and performance improvement for resource utilization and cost-effective care.
• Ensure medical necessity criteria are met and communicate discharge plan changes as needed.
• Coordinate discharge planning and utilization management with staff to support medical necessity.
• Perform other job-related duties as assigned.

Skills

Nursing experience

Communication skills

Education

BSN preferred

Job description

JOB DESCRIPTION

Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect. Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work.

Job Summary:

Manages the development, implementation and evaluation of the cavitation care management service lines. Enhances the quality of member management by promoting continuity of care and cost effectiveness through whole person in-patient and out-patient management, care integration, case management, utilization review and care planning.

Job Requirements: Education and Work Experience:

• Bachelor's Degree in Nursing (BSN): Preferred
• Nursing experience: Preferred

Licenses/Certifications:

• Certified Case Manager (CCM): Preferred
• Registered Nurse (RN) licensure in the state of practice: Required

Essential Functions:

• Partners with internal and external physician advisors, as well as claims department and data management and analytics department to provide safeguards, processes and expected outcomes for the Health Plan's member population. Perform and/or coordinate preventative care, wellness, and nutritional counseling to Members. Develops and maintains positive relationships with customers internal and external.
• Works collaboratively with physicians, staff and service line leadership on quality and performance improvement activities related to optimal utilization of resources, efficient delivery of high quality care, patient flow, capacity management and other clinical cost reduction initiatives.
• Performs ongoing collaboration with staff to ensure a member's medical condition meets medical necessity criteria. Communicates changes that could affect the discharge plan of care.
• Manages communication related to discharge planning and utilization management. Performs ongoing collaboration with staff to ensure condition meets medical necessity criteria.
• Performs other job-related duties as assigned.

Organizational Requirements:

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply. Adventist Health participates in E-Verify. Visit for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.

ABOUT US

Adventist Health is a faith-based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of more than 38,000 includes employees, physicians, Medical Staff, and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.