Utilization Review Case Manager

Palomar Health; Escondido (CA); On-site; USD 75,000 - 109,000; Full time

Job summary

Palomar Health is seeking a Clinical Resource Management RN to drive utilization management for acute care patients. You will conduct daily concurrent reviews, support discharge planning, and communicate with health plans and case managers to ensure appropriate care and timely authorization.

In this role you will collaborate with the care team during Interdisciplinary Rounds, participate in denial reviews and appeals, and analyze utilization patterns.

Qualifications

• Minimum Education: As required by certification and/or licensure.
• Preferred Education: Bachelor's Degree and/or National Certification in Utilization Review or Case Management.
• Minimum Experience: 1-3 years of directly related RN experience.
• Preferred Experience: 3-5 years acute care nursing experience.
• Required Certification: Not Applicable
• Required License: Current CA RN License

Responsibilities

• Implement utilization management for patients admitted to acute care.
• Conduct daily concurrent reviews for utilization/quality management.
• Provide telephonic or fax reviews to health plans/medical groups.
• Collaborate with Case Managers and care team during Interdisciplinary Rounds.
• Participate in retro reviews and appeals for denied services.
• Analyze utilization patterns and support data collection for studies.

Skills

RN experience

English proficiency

MS Windows

Excel

Access

Word

PowerPoint

Keyboarding

Education

Bachelor's degree or higher

National Certification in Utilization Review or Case Management

Tools

MS Windows

Excel

Access

Word

PowerPoint

Job description

Department: Clinical Resource Management Union: CNA Shift: 8-hour Shift - Day (United States of America) Hours Per Pay Period: 80 Job Description: Pay range: $54.15 - $78.82 Posting Date: 9/15/2026 Internal Closing Date: 9/21/26 * Internal candidates must apply by midnight on the Closing Date in order to have bidding rights. Responsible for implementing the utilization management process for patients admitted to acute level of care. Conducts daily concurrent clinical reviews for utilization/quality management activities, based on acute care guidelines/standards with focus on appropriateness of admission, monitoring length of stay, and discharge delays. Provides telephonic or fax reviews to multiple health plans/medical groups. Communicates the plan of care to various Case Managers with focus on information received related to patient progress, cultural diversities, patient's age, socioeconomic status, lifestyle, and advanced directives. Collaborates with the care team during Interdisciplinary Patient Rounds providing direction to the physician, nursing, and other members of the health care team in the development, implementation, and documentation of an appropriate, safe continue care plan. Provides retro review of identified cases denied by health plans for financial reimbursement. Participates in appeals process to recover funds for services rendered by Palomar Health and ensures that patients/families understand their rights to appeal when they disagree with a medical determination. Analyzes and identifies utilization patterns and trends and participates in the collection and analysis of data for the denial process as well as special studies, projects, audits, or routine utilization monitoring activities. Receives ongoing education related to State and Federal health care programs, managed care organizations, preferred provider health plans, worker compensation plans, private health plans, third party payers, and criteria for continued care at multiple levels. Functions as key resource provider related to health care management, delivery of care, and effects of reimbursement on both patients and health care system. Understands and adheres to the California Nurse Practice Act, The American Nurses Association (ANA) Code of Ethics for Nurses, the ANA Bill of Rights for Registered Nurses and the ANA Scope and Standards of Practice for Nursing. Speak and read English at a level that is sufficient to satisfactorily perform the essential functions of the position. Knowledge of standard office equipment (i.e., calculator, fax, photocopier) and personal computer and computer software skills (i.e., MS Windows, Excel, Access, Word, Powerpoint, internet, e-mail). Windows computer skills including proficient use of keyboarding, use of mouse or keys for functions such as selecting items, use of drop down menus, scroll bars, opening folders, copying and similar operations required upon employment or within the 1st two weeks of employment to perform the essential functions of the job. Performs other duties as assigned.

Follows Palomar Health rules, policies, procedures, applicable laws and standards. Carries out the mission, vision, and quality commitment of Palomar Health.

Job Requirements Minimum Education: As required by certification and/or licensure Preferred Education: Bachelor's Degree and/or National Certification in Utilization Review or Case Management Minimum Experience: 1 - 3 years of directly related RN experience Preferred Experience: 3 - 5 years acute care nursing experience Completion of Utilization Review/Case Management course Required Certification: Not Applicable Preferred Certification: Not Applicable Required License: Current CA RN License Preferred License: Not Applicable

We are an equal opportunity employer and do not discriminate against applicants or employees based on race, color, gender, religion, creed, national origin, ancestry, age, disability, sexual orientation, marital status or any other characteristic protected by law.

Palomar Health invites you to be part of our healthcare team, where we offer extraordinary opportunities for both clinical and non-clinical positions. As a leading healthcare system, we are committed to providing world-class care to our community. When you join our team, you'll have access to our exceptional training programs designed to help you excel in your role and grow your career.