Utilization Review/Case Management RN

Celsior; Santa Clara (CA); On-site; USD 103,320 - 117,096; Full time

Benefits offered by this job

Health insurance (medical, dental, vision)

401(k) plan

Paid sick leave

Job summary

Celsior is urgently hiring a Utilization Review/Case Management RN for a 3-month contract in Santa Clara, CA. This role involves conducting reviews and coordinating patient discharge plans while collaborating with healthcare teams.

Ideal candidates will have a minimum of two years in acute care settings and hold a California RN license. The position offers competitive pay and comprehensive employee benefits, including health insurance and 401(k).

Qualifications

• Minimum two years of experience in utilization review, case management, and discharge planning.
• Graduate of an accredited school of nursing.
• Knowledge of Nurse Practice Act and various healthcare regulations.

Responsibilities

• Perform daily pre-admission, admission, and concurrent utilization reviews.
• Monitor progression of discharge plans.
• Collaborate with multidisciplinary teams for patient discharge.

Skills

Communication skills

Problem-solving skills

Critical thinking

Clinical judgment

Customer service

Education

Registered Nurse License (California)

Diploma/Associate Degree in Nursing

Bachelor's degree in nursing or related field

Master's degree in case management (preferred)

Tools

Basic Life Support (BLS)

Health-care benefits knowledge

Job description

Immediate need for a talented Utilization Review/Case Management RN

03+ Months Contract opportunity with long‑term potential located in Santa Clara, CA (Onsite). Pay Range: $75 – $85/hour. Employee benefits include health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).

Job ID: 25-96149

Key Responsibilities:

• Perform daily pre‑admission, admission, and concurrent utilization reviews using guidelines, institutional policies/procedures, and other information to determine appropriate levels of care and readiness for discharge.
• Monitor progression of the discharge plan and facilitate discussions with multidisciplinary teams.
• Educate other healthcare team members on utilization and care coordination.
• Collaborate with and provide information to patients, families, physicians, and staff regarding discharge plans and transitions.
• Understand and consistently apply interpretation and utilization of member health‑care benefits.
• Conduct utilization management, care coordination, and discharge planning activities according to all applicable regulatory requirements.
• Ensure continuity of care through communication in rounds and written documentation, level‑of‑care recommendations, transfer coordination, discharge planning, and obtaining authorizations/approvals as needed for outside services for the patient.
• Develop, evaluate, and coordinate a comprehensive discharge plan in conjunction with the patient/family, physician, nursing, social services, and other health‑care providers and agencies.
• Shift timings: 8:00 AM – 4:30 PM, 5 days/week including every other weekend (both Saturday & Sunday).
• Provide schedule for two travelers as needed.

Key Requirements and Technology Experience:

• Recent hospital/acute care setting experience.
• Strong discharge planning background.
• Availability aligned with outlined shift schedules.
• Minimum two (2) years of experience in utilization review, case management, and discharge planning.
• Graduate of accredited school of nursing.
• Diploma/Associate Degree in Nursing.
• Registered Nurse License (California) – Required upon hire.
• Basic Life Support (BLS) – Required upon hire.
• Knowledge of Nurse Practice Act, TJC, DMHC, CMS, NCQA, HIPAA, ERISA, EMTALA, and all other applicable federal/state/local laws & regulations.
• Strong communication, customer service, problem‑solving, critical thinking, and clinical judgment skills.
• Fundamental word processing & computer navigation skills and ability to interpret & use analytic data in day‑to‑day operations.
• Knowledge of health‑care benefits associated with Medicare/KPSA, Commercial/KFH, Medi-Cal, Federal, etc.
• Must be able to work in a Labor/Management Partnership environment.
• Acute inpatient hospital-level experience.
• Bachelor's degree in nursing or a related field preferred.
• Master's degree in case management preferred.

Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.