Nurse, (RN) Case Manager

The Nurse Case Manager may provide daily care coordination, case management, coaching, consultation and intervention to patients with one or more chronic diseases. May also be responsible for identifying said population via provider/clinic referral, utilization management referral, disease registry reporting mechanisms and patient self-referral. This position may also provide case management to patients who are admitted to the hospital and those patients who may need to be enrolled in ambulatory case management.  The case manager will be responsible for identifying (California Children Services) CCS cases, handle transfers, and retro reviews.  Works as part of an interdisciplinary care team coordinating social work and mental health counseling, psycho-social support services, in-home support, legal services, skilled nursing, home health, etc.  The Nurse Case Manager effectively collaborates with the hospitalist, the hospital nursing personnel, with members of the interdisciplinary care team and with the physician in the clinic.

1. May be responsible for daily concurrent reviews, retro reviews, discharge planning, and ensures patients meet appropriate level of care based on acceptable evidence-based Clinical Criteria(s).


2. Effectively and efficiently manages patients throughout the continuum of care.


3. Works collaboratively with Hospitalists, hospital partners, and care teams to provide holistic patient care that is focused on high quality in a cost effective way.


4. Will participate in the developing of all program material, Policies and Procedures related to the nurse case management program; may also develop program informational and educational materials and various forms.


5. Develops a working relationship with the hospital case managers, health plan, clinics, hospitalists and other governing entities.


6. Identifies and enrolls patients into a case management program providing intensive service.


7. Conducts intakes and comprehensive assessments per health plan and department’s policy.


8. Identifies needs and develops individualized care service plans on behalf of clients; an active participant in case conferences; attends divisional coordinators meetings and regular staff meetings; re-evaluates patients as needed; monitors the services delivered by team participants.


9. Works with hospital discharge planners and assists in the coordination of support services.


10. Attends Joint Operation Committee (JOC) meetings and various community meetings as needed.


11. Responsible for the daily review and processing of referral authorizations in accordance to turnaround time (TAT) standards set by ICE/Health Plan requirements.


12. Assist with composing medical director denials to meet language requirements set by ICE/Health Plan requirements.


13. Perform and document patient telephonic and/or person-to-person risk assessments as needed.


14. Monitor ongoing services and their cost effectiveness; recommending changes to the plan as needed using clinical evidence-based criteria – Milliman, Interqual, CMS, National Recognized American Academy of Specific Specialty.


15. Performs other related duties as assigned.

1. Graduation from an accredited nursing program.


2. Current valid License as a Registered Nurse through the California Board of Registered Nursing; Bachelor’s degree in social work, nursing, or another health or human services field with the appropriate licensure preferred.


3. Experience in and willingness to be part of multi-disciplinary team.


4. Experience with physically or mentally impaired adults and/or geriatric population.


5. Three years experience in public health nursing, acute care, case management and/or in-home health care required; minimum of 2 years of managed care experience in case management with focus in inpatient and/or outpatient ambulatory care preferred.


6. Bilingual in English and Spanish preferred.