RN Medical Management & Care Coordination Specialist

SCAN Health Plan; California; On-site; USD 62,000 - 69,000; Full time

Job summary

SCAN Health Plan in Long Beach, CA is seeking a Medical Management Specialist RN to promote medical necessity, quality, and cost-effectiveness of care for its older adult members.

The role requires 3+ years in medical-surgical nursing and utilization management in managed care, with active CA RN licensure. CPUM/CPUR preferred or obtainable within 2 years. Full-time, on-site position with standard M-F hours.

Qualifications

• Current and active California RN license required.
• CPUM or CPUR certification preferred or willing to attain within 2 years.

Responsibilities

• Ensure necessary inpatient and outpatient care is rendered to SCAN members.
• Issue determinations within required regulatory timeframes.
• Collect relevant information and apply evidence-based criteria and guidelines.
• Escalate requests to Medical Director following established guidelines.
• Manage complex medical cases through assessment, planning, and coordination.
• Prepare and deliver case presentations and participate in interdisciplinary team meetings.
• Assist members requiring urgent and emergent medical and behavioral health services.
• Authorize care and services needed for stabilization.
• Facilitate safe and effective discharges from inpatient settings.
• Maintain documentation and data entry requirements adhering to all policies.

Skills

Nursing expertise

Utilization management

Care coordination

Education

Nursing degree

Job description

SCAN Health Plan in Long Beach, CA is seeking a Medical Management Specialist RN to promote medical necessity, quality, and cost-effectiveness of care for its older adult members.

The role requires 3+ years in medical-surgical nursing and utilization management in managed care, with active CA RN licensure. CPUM/CPUR preferred or obtainable within 2 years. Full-time, on-site position with standard M-F hours.