Five years of clinical experience in an acute healthcare setting.
Proficiency in Interqual or Millennium Guidelines.
At least one year of experience in utilization review.
Familiarity with healthcare database systems.
Bachelor's or Master's degree in Nursing (BSN/MSN) required.
Responsibilities
Utilize clinical expertise to coordinate patient care across the continuum.
Review clinician assessments and patient support systems for hospitalization justification.
Assess admission status, level of care, and payer source for billing validation.
Document patient issues and discharge plans during medical reviews.
Communicate with physicians to ensure proper insurance authorizations are secured.
Assist in providing justification for insurance appeals and denials.
Educate patients and families on changes in the level of care.
Benefits
Comprehensive health insurance options.
Retirement savings plan with employer matching.
Continuing education and professional development opportunities.
Flexible work schedules to promote work-life balance.
Supportive team environment focused on patient care.
Full Job Description
JOB DESCRIPTION
Primary Duties and Responsibilities
The Care Manager (RN) utilizes clinical expertise, patient assessments, and insurance payer requirements to coordinate patients27 needs through the continuum of care including post-acute care and discharge plans. This role includes reviewing clinician assessments and patients27 financial, family and psychosocial support to justify hospitalization for clinical reviews. Duties include reviewing records to assess appropriate admission status, level of care, payer source, and UR contracts to validate billing. Documents pertinent patient issues, contacts and discharge plans on medical reviews. Communicates with physicians and medical offices to confirm appropriate insurance authorizations are in place. Assists with providing proper justification for insurance appeals and denials as needed. May educate patients and families on appropriate level of care changes.
JOB QUALIFICATIONS
Education and Experience
Five years of clinical experience in an acute healthcare system environment.
Experience in Interqual or Millennium Guidelines required.
One year of experience in utilization review required.
Experience with healthcare database systems
Care Manager II (RN) 61Bachelor27s or Master27s degree in Nursing (BSN/MSN).
License Required
Registered Nurse (RN) license for Care Manager II (RN) position
License Preferred
N/A
Certifications Required
N/A
Certifications Preferred
Utilization Review
Care Management
Clinical Nursing
About Hoag Memorial Hospital Presbyterian
Hoag Memorial Hospital Presbyterian is a non-profit hospital located in Newport Beach, California. It was founded in 1952 and has since grown to become one of the largest hospitals in Orange County. Hoag offers a wide range of medical services, including cancer care, heart and vascular care, neurosciences, women's health, and orthopedics. The hospital is known for its commitment to patient-centered care and has received numerous awards and recognitions for its quality of care.
