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Case Management Nurse

2 months ago

San Mateo, California, United States County of San Mateo (CA) Full time
Job Summary

We are seeking a highly skilled Case Management Nurse to join our team at the County of San Mateo Medical Center. As a Utilization Review Case Management Nurse, you will play a critical role in ensuring that patients receive the highest quality care while also optimizing resource utilization.

Key Responsibilities
  • Manage patient admission and ongoing stay reviews for patients with complex medical conditions and oversee appeals with third-party payors.
  • Conduct retrospective and concurrent Utilization Review activities and monitor order status accuracy, documentation, and clinical compliance in accordance with State and Federal regulations.
  • Collaborate with the healthcare team to coordinate quality healthcare services that meet the patient's needs across the continuum of care.
  • Develop and implement effective discharge plans, appeals for acute days, and clinical denials, as well as criteria for lower-level license care.
  • Interpret and apply health industry utilization review criteria.
Requirements
  • Associate Degree in Nursing with two years of clinical experience, including one year in a clinical specialty area, or
  • Baccalaureate Degree in Nursing or a health-related field with one year of clinical experience, including six months in a clinical specialty area, or
  • Masters degree in Nursing.
  • At least two years of experience in Nurse Case Management in an acute care setting or at least two years of acute care hospital nursing experience.
  • Basic Life Support (BLS) certificate.
  • Experience working with diverse, underserved populations.
Preferred Qualifications
  • Knowledge of and experience with industry-published standards of level of care (e.g., InterQual or Milliman).
  • Experience with psychiatric patient treatment trajectory and utilization review criteria.
What We Offer
  • A dynamic and supportive work environment.
  • Opportunities for professional growth and development.
  • A competitive salary and benefits package.