Inpatient Nurse Case Manager

$104,000 - $145,600/Yr

Altais - Newport Beach, CA

Full-time - Mid Level

Remote - Newport Beach, CA

1,001-5,000 employees

About the position

The Inpatient Nurse Case Manager at Altais is responsible for coordinating patient care across the healthcare continuum, ensuring that members receive appropriate levels of care from admission through discharge. This role involves conducting onsite visits to local hospitals, performing concurrent reviews, and collaborating with various stakeholders to facilitate timely discharge planning and effective case management. The position requires a strong clinical background and the ability to navigate complex healthcare systems to advocate for patients' needs.

Responsibilities

• Conduct onsite or electronic concurrent reviews to assess, plan, implement, coordinate, monitor, and evaluate options and services needed for members' health needs.
• Ensure members are at the appropriate level of care from admission through discharge and provide timely discharge planning.
• Utilize clinical knowledge to evaluate requests for authorization, including screening for appropriateness and verifying eligibility.
• Research issues to facilitate objective medical management decisions based on approved criteria and guidelines.
• Communicate regularly with internal and external partners regarding clinical decisions and timely access to care.
• Assess and triage patients, providing concise SBAR to medical directors to support decision-making.
• Conduct clinical reviews as required by health plan delegation agreements to resolve challenges and service denials.
• Issue facility denial letters as appropriate to the hospital.
• Provide case management activities across the continuum of care to promote high-quality, cost-effective outcomes.
• Assist in the development, implementation, and evaluation of care standards, policies, procedures, and protocols.

Requirements

• Bachelor of Nursing degree preferred.
• Current California unrestricted RN or LVN license required.
• Minimum of three (3) years recent acute clinical experience in a hospital setting required.
• Managed care experience desirable.
• Discharge planning experience preferred in an acute care or skilled nursing facility.
• Basic computer skills including electronic medical records, Outlook email, and Microsoft Office suite.
• Ability to read and understand inpatient medical records and extract pertinent data.
• Effective verbal and written communication skills to represent the organization and advocate for patients.
• Working knowledge of utilization management, reimbursement, and medical necessity criteria including InterQual.
• Knowledge of managed care concepts and Medicare/Medi-Cal guidelines.

Nice-to-haves

• Experience in utilization management.
• Experience in managed care settings.

Benefits

• 401(k) matching
• Dental insurance
• Employee assistance program
• Health insurance
• Paid time off
• Parental leave
• Referral program
• Vision insurance