Utilization Management Lead — Inpatient Case Management (RN)

📋 Description

• Perform initial admission and concurrent review for delegated inpatient and SNF admissions
• Prepare clinical summaries and route cases that do not meet criteria to the Medical Director for
• Coordinate with facility case managers on continued stay, discharge readiness, and post-acute
• Document reviews, determinations, and rationale in EZCap and maintain compliance with notification
• Own post-discharge follow-up for members discharged from inpatient and skilled nursing facilities
• Operationalize the ADT/TCM notification feed: define which events trigger outreach, set response

🎯 Requirements

• Active, unrestricted California RN license (required)
• 5+ years of clinical experience, including 3+ years combined in inpatient utilization management
• Working knowledge of MCG criteria and inpatient status determination
• Experience with transitions of care, discharge planning, and post-acute coordination for Medicare
• Experience building or scaling a care management program, or demonstrated ownership of
• Certified Case Manager (CCM) or equivalent certification (preferred)