[Hiring] Case Manager II @Sutter Health

Role Description

Conducts concurrent utilization management reviews for hospitalized and acute care patients using established clinical criteria and evidence-based guidelines to evaluate medical necessity, appropriateness of care, continued stay, and level-of-care requirements. Assesses the patient’s clinical status and progression of care throughout the hospitalization to support timely, appropriate, and effective utilization of healthcare services.

• Collaborates with physicians, hospital care teams, case management, health plans, post-acute providers, and other stakeholders to identify barriers to progression of care, support timely transitions, and facilitate appropriate discharge planning and post-acute services.
• Escalates cases requiring additional clinical review or physician involvement in accordance with regulatory, health plan, and organizational requirements.
• Prioritizes concurrent reviews based on clinical urgency, required review intervals, regulatory and health plan turnaround times, and organizational standards.
• Monitors continued-stay reviews, length of stay, level of care, documentation needs, and discharge readiness to promote timely clinical decision-making and reduce avoidable delays in care.
• Maintains accurate and timely documentation to support medical necessity determinations, communication with providers and health plans, regulatory compliance, and audit readiness.
• Ensures adherence to applicable CMS, DMHC, health plan, and organizational requirements related to utilization management, physician review, notifications, and coordination of care.
• Promotes patient-centered care, quality outcomes, safe transitions, and responsible utilization of healthcare resources while supporting regulatory compliance, patient safety, and organizational stewardship for patients with complex acute and post-acute care needs.

Qualifications

• Graduate of an accredited school of nursing.
• RN-Registered Nurse of California.
• 2 years of experience in acute care case management or health plan case management/utilization management required.

Requirements

• A broad knowledge base of health care delivery and case management within a managed care environment.
• Comprehensive knowledge of Utilization Review, levels of care, and observation status.
• Working knowledge of laws, regulations and professional standards affecting case management practice in an integrated delivery system, including but not limited to: Centers for Medicare and Medicaid Services (GR) Grouper (CMS), Department of Managed Health Care, National Committee for Quality Assurance (NCQA).
• A broad knowledge base of outpatient, acute, and post-acute levels of care and associated regulatory compliance requirements.
• Must be able to effectively communicate with and promote cooperation and collaboration between individuals including patients/families/caretakers, physicians, nurses and other ancillary partners.
• Ability to work independently and exercise sound judgment in interactions with physicians, payers, and patients and their families.
• Demonstrates commitment to service excellence in all patient, family, and employee interactions and in performing all job responsibilities.
• Functions in a manner to promote quality patient care and assure a positive patient experience.
• Verbal and written communication skills.
• Interpersonal communication and negotiation skills.
• Must have time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities.
• Intermediate computer skills.
• Ability to promote teamwork and to effectively function in teams.
• Ability to interact effectively with key internal and external constituents using collaboration, and customer service skills that promote excellence in the patient experience.

Benefits

• Comprehensive benefits package.

Company Description

Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

Pay Range is $82.48 to $115.46 / hour. The posted pay range is based on the position's primary work location. Candidates who reside and work outside of that location may be subject to a different pay range based on their work location. Candidate starting salaries consider multiple factors, including, but not limited to a candidate’s experience, education, skills, licensure, certifications, departmental equity, training, and organizational needs. Base pay is only one component of Sutter Health’s comprehensive total rewards program.