Provides remote weekend inpatient utilization review for seniors and medically complex members, focusing on admission review, continued-stay review, and determining the appropriate level of care using evidence-based guidelines. The role also supports discharge planning and follow-up care across ambulatory and lower-acuity settings, with attention to complex medical and social needs. Collaborates closely with physicians, case managers, discharge planners, ancillary providers, and community resources to coordinate safe, cost-effective care.
Key Responsibilities
- Conduct inpatient reviews for members with complex medical and social needs.
- Review admissions and continued stays using Milliman Care Guidelines and other evidence-based criteria.
- Coordinate with primary care physicians, facility case managers, discharge planners, and ancillary providers.
- Provide follow-up review for patients transitioning to ambulatory or lower levels of care.
- Identify members who may need complex or chronic case management after discharge and facilitate warm handoffs.
- Document communications, clinical criteria, and case activity in case management systems.
- Participate in multidisciplinary care conferences and patient care rounds.
- Monitor for overutilization and underutilization and generate appropriate referrals to quality management or community resources.
Required
- Active, valid, unrestricted California LVN or RN license.
- Successful completion of an accredited Licensed Vocational Nursing program.
- At least 3 years of general case management experience.
- At least 2 years of experience using Milliman Care Guidelines to support inpatient versus observation status decisions.
- At least 2 consecutive years of related experience in a managed care setting as an inpatient case manager.
- Availability to work every Saturday and Sunday on a Pacific Time schedule.
Preferred
- Experience working with a senior population.
- Associate’s or bachelor’s degree.
- Experience in complex or catastrophic case management.
Benefits & Perks
- Remote work arrangement.
- Part-time weekend schedule.
- Company-reimbursed licensure in Nevada, Arizona, North Carolina, and Texas upon hire.
- Pay range of $77,905 to $116,858.