RN Case Manager, Utilization Review
Ventura, CA
American Traveler
5x8 hrs, Days

Assignment Overview

• Shift: Days, 5x8hrs
• Hours: 40 hrs/wk
• Start Date: Jul 6, 2026
• Length: 13 weeks
• Openings: 1

Description

American Traveler is seeking an experienced RN Case Manager for a hospital-based utilization review role requiring strong MCG proficiency and a minimum of 3 years of acute care CM/UR experience in Ventura County, CA.

Details

• Hospital setting with an average daily census of 180 patients
• Patient population spans adolescents through geriatrics
• Case Management/Utilization Review unit
• Day shift schedule: Monday–Friday, 8:30 AM–5:00 PM (5x8 hours)
• Every other weekend required, totaling 4 weekend shifts over 4 weeks
• EMR: Cerner; communication framework: SBAR
• Case management module used for concurrent documentation, tracking, and outcome recording

Requirements

• Active CA RN license required
• Current BLS certification required
• CCM or other case management certification preferred
• Minimum 3 years of acute care Case Management/Utilization Review experience required
• Strong proficiency in utilization review using MCG guidelines required
• Thorough understanding of the Two Midnight Rule required
• Experience with Cerner EMR preferred
• 2 professional supervisor references from within the past 2 years required for consideration
• Full 7-year work history with all gaps explained required for consideration

Additional Information

• Performs concurrent utilization review using MCG guidelines to validate patient status and medical necessity
• Applies evidence-based screening criteria for admission, continued stay, and discharge reviews
• Ensures appropriate level-of-care status for all bedded outpatient services requiring hospital admission
• Provides clinical reviews to health plans and responds to payer requests in a timely manner
• Educates physicians and the care team on patient status changes, including transitions from observation to inpatient
• Coordinates concurrent Peer-to-Peer calls and participates in the appeals process as needed
• Adheres to regulatory procedures including MOON, IMM Discharge, Appeal/HINN, Code 44, and Inpatient Only Procedure guidelines
• Collaborates with case managers and payers to ensure authorizations are obtained and current
• Assists with denial management to identify process improvement opportunities
• All time-off and scheduling requests must be submitted at the time of initial consideration