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Utilization Management

Rancho Cordova, California | Contract

Job ID: 55572 Position: Registered Nurse Branch: Rancho Cordova


Working with complex cases promotes the delivery of quality; cost-effective health care services based on medical necessity and contractual benefits. Works with other members of HCS team, provider, hospitals, members and their families to plan and review medical necessity, intensity of services, level of care, length of stay and general appropriateness of care. Provides guidance to the provider network. Performs effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of care. May provide referrals for case management to member segments with chronic illness i.e., disease management, Quality Management and Appeals and Grievance Department.

Discharge planning for cases that exceed Extension of Authority or dx assigned to RN. Coordinates Care for Lower Level of Care coordination such as Skilled Nursing Facility, Home Health, Home Infusion, Rehab. Ability encompasses broad knowledge of concepts, practices and procedures required within health care field. Uses concepts and abilities as well as internal policies and procedures to complete assignments and solve problems Reviews cases for Continuity of Care and invest/exp requests

Support to senior/lead CMs as needed.

Generally requires moderate to thorough experience in nursing, health care or related field. (5 years)

Current active unrestricted CA RN License. Bachelor of Science in Nursing or advanced degree preferred.

Able to operate PC-based software programs including proficiency in Word and Excel. Strong clinical documentation skills, independent problem identification and resolution skills

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