Travel Nurse RN - Case Manager - $3,052 per week in Sacramento, CA

Job Title : Case Manager Profession : Registered Nurse Specialty : Utilization Management Duration : 24 weeks Shift : Day Hours per Shift : 8 hours (08 : 00 - 16 : 30) Experience : Minimum of 2 years of acute / inpatient case management experience required License : Current Registered Nurse License required Certifications : AHA or American Red Cross certifications required Must-Have : Epic charting system experience preferred Description : Conduct preauthorization, concurrent, and retrospective utilization management review using accepted criteria for ambulatory, acute, and post-acute patients to confirm medical necessity. Coordinate utilization management, resource management, discharge planning, post-acute care referrals, and care facilitation. Promote patient wellness, improved care outcomes, and efficient utilization of health services among a patient population with complex health needs. Provide inpatient and ambulatory referral review, managing prior authorizations and retrospective referrals as documented. Process referrals based on application of criteria such as Medicare, MCG, and InterQual. Collaborate with medical directors routinely regarding referrals and cases not meeting criteria. Issue appropriate authorization and denial letters as needed. Work collaboratively with staff to handle daily tasks. Document all referral activities thoroughly. Conduct preauthorization, concurrent, and retrospective review for acute hospitalized and post-acute patients. Consult with facility care teams to develop goals to enhance functional status, identify discharge planning needs, and ensure continuity of care. Document applicable guidelines and rationale for cases not meeting criteria, routing to the medical director for further review. Issue and document facility or regulatory letters as applicable. Actively participate in interdisciplinary meetings in acute or post-acute settings. Facilitate repatriation of out-of-network patients and escalate as necessary. Identify and refer patients to value-based case management teams as appropriate. Comply with health plan and regulatory prior authorization turnaround timeframes. Understand health plan contracts and associated responsibilities.