* Four 10-hour Rotational Shifts *

Under the direction of the Senior VP of Medical Management, the Acute Case Manager is responsible for the clinical review, coordination and management of members admitted to acute care hospitals, including high-acuity, high complexity cases at tertiary and quaternary care facilities. Responsibilities include concurrent utilization review, medical necessity determination, discharge planning, care coordination, and transition management across the continuum of care.

This position requires advanced clinical judgment in managing medically complex patients requiring specialized services such as trauma, transplant, advanced cardiac care, neurosurgery, oncology, critical care, and other tertiary-level services. The Acute Case Manager collaborates with physicians, hospital staff, health plan leadership, community providers, patients, and families to ensure appropriate utilization of healthcare resources while promoting safe, efficient, and high-quality patient outcomes.

This position requires travel to tertiary care facilities in Southern California approximately one day per week. Additional travel may be required based on departmental and operational needs.

• Provides case management coverage for acute care patients on a rotational schedule based on departmental needs, including members hospitalized at tertiary referral centers and high-complexity facilities throughout California.
• Assumes responsibility for assigned patients in acute care hospitals, including patients requiring highly specialized services and multidisciplinary care coordination.
• Performs comprehensive initial patient assessment to evaluate medical, psychosocial, functional, and discharge planning needs. Assessment includes:
  • Activity level.
  • Power of Attorney or designated contact
  • Durable Medical Equipment needs
  • Baseline functional status
  • Primary Caregiver
  • Home support system
  • Social determinants of health and barriers to care
  • Advanced Directives
  • Anticipated discharge needs
  • Medical History
  • Admission diagnosis
  • Disease process education
  • Initial discharge planning
  • Verification of contracted consulting physicians
  • Identification of specialty service needs
  • Evaluation for transfer to tertiary or specialty facilities when appropriate
• Performs daily concurrent utilization review to determine medical necessity, appropriate level of care, and progression toward discharge. Responsibility includes:
  • Comprehensive chart review utilizing approved utilization review criteria.
  • Documentation of procedures, specialty consultations, and clinical progression
  • Identification and escalation of barriers to treatment, discharge, or placement.
  • Coordination with hospital staff to expedite diagnostics, procedures, specialty consultations, and transfers.
  • Facilitation of timely progression through the continuum of care.
  • Monitoring avoidable days and reporting per organizational policy.
  • Daily verbal or telephonic clinical sign-out with the Senior VP of Medical Management or designee.
  • Daily electronic patient sign-out before the end of each shift.
  • Active management of patients requiring tertiary services, transfers, or highly specialized post-acute care.
• Maintains ongoing communication with attending physicians, specialists, hospital case managers, and interdisciplinary teams regarding treatment plans, utilization concerns, patient progression, barriers to care, and discharge readiness.
• Collaborate with physicians to identify discharge needs and proactively remove barriers that may delay transitions of care.
• Coordinates comprehensive discharge planning for routine and medically complex patients, including those requiring:
  • Long-Term Acute Care Hospitals
  • Inpatient Rehabilitation
  • Skilled Nursing Facilities
  • Home Infusion
  • Home Health
  • Hospice
  • Complex Durable Medical Equipment
  • Specialty outpatient service
• Participates in daily utilization review rounds with the Medical Director and Senior VP of Medical Management.
• Proactively identifies evidence-based treatment options and appropriate levels of care.
• Coordinates information gathering to ensure continuity of care across hospitals, tertiary centers, post-acute providers, and outpatient services.
• Assists with complex clinical issues and special projects as assigned.
• Coordinates transitions between levels of care including transfers to tertiary referral centers, specialty hospitals, rehabilitation facilities, and community resources.
• Educates patients and caregivers regarding Advance Directives and healthcare decision-making.
• Maintains positive and collaborative relationships with providers, patients, families, hospitals, and community partners.
• Ensures seamless transitions following discharge through coordination of services and follow-up care.
• Participates in emergency response activities including Code Red, Code White, and Code Blue when appropriate.
• Demonstrates effective interdisciplinary communication across multiple healthcare settings.
• Maintains knowledge of contracted hospitals, tertiary referral centers, specialty providers, and healthcare resources.
• Acts proactively in the best interest of patients regardless of care setting.
• Communicates utilization concerns and clinical issues promptly to attending physicians and Medical Management leadership.
• Maintains working knowledge of contracted facilities, specialty services, and referral resources.
• Evaluates each patient's support system, caregiver availability, and community resources.
• Understands member benefits and educates patients regarding covered services and available resources.
• Assists patients and families with advance care planning, durable power of attorney, resuscitation decisions, and financial resource referrals when appropriate.
• Demonstrates flexibility in scheduling and coverage based upon departmental needs, including travel assignments.
• Coordinates care for members receiving treatment at tertiary referral centers, ensuring timely communication between specialty providers, referring physicians, and health plan leadership.
• Provides clinical oversight for high-complexity cases involving multiple specialties, prolonged hospitalization, critical illness, transplant evaluation, trauma, oncology, neurosurgery, cardiovascular surgery, or other specialized services.
• Travels to Southern California approximately one day per week to conduct on-site case management activities, interdisciplinary rounds, provider collaboration, and utilization review at designated tertiary facilities.

• Graduate from an Licensed Vocational Nursing program or accredited Registered Nursing program.
• Current California LVN or RN license.
• Current BLS certification.
• Minimum of three (3) years of acute care clinical nursing experience, preferred.
• Minimum of two (2) years of Utilization Review and/or Acute Case Management experience preferred
• Experience managing medically complex patients in acute care, tertiary care, trauma, academic medical centers, or specialty hospitals strongly preferred.
• Demonstrated knowledge of InterQual®, MCG®, CMS regulations, discharge planning, and care transitions preferred.
• Excellent communication, critical thinking, organizational, and interdisciplinary collaboration skills.
• Ability to travel independently to hospitals throughout Southern California approximately one day per week.
• Proficiency with electronic medical records, utilization management software, and Microsoft Office applications.

Travel Requirements:

• This position requires regular travel to contracted hospitals, including weekly travel to tertiary care facilities in Southern California. Reliable transportation, a valid California driver's license, proof of automobile insurance and a clean driving record are required.

The pay range for this position at commencement of employment is expected to be reasonably between $37.46 and $44.07. However, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, skills, and experience.

If hired, employee will be in an "at-will position" and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.