Local Contract Nurse RN - Case Manager, Utilization Review
Irvine, CA
Apidel Technologies
3x12 hrs, Days
Referral Bonus

Job Tittle: RN Case Manager
Duration: 3 Months ( Possibility to extend or convert)
Shift: Day 3x12-Hour (07:00am - 7:30pm)
Location: : Irvine, CA

Job Summary:
The Case Manager/Utilization Review RN is responsible for coordinating patient care, managing utilization review activities, ensuring medical necessity compliance, and facilitating discharge planning for acute and specialty hospital patients. This role works collaboratively with interdisciplinary teams to support quality outcomes, regulatory compliance, and appropriate resource utilization.
The ideal candidate will have strong experience in acute inpatient case management, utilization review, InterQual/Milliman guidelines, and complex care coordination within hospital settings.

Key Responsibilities:
• Perform inpatient case management and utilization review for complex acute care patients
• Conduct admission reviews, concurrent reviews, continued stay reviews, and retrospective reviews
• Evaluate medical necessity using InterQual and Milliman guidelines
• Coordinate patient care plans, discharge planning, and transitions of care
• Collaborate with physicians, nursing staff, social workers, and interdisciplinary teams
• Manage appeals, denials, and authorization processes
• Utilize Epic EMR for documentation and case management workflows
• Communicate patient status and recommendations using SBAR communication methodology
• Ensure compliance with CMS, HIPAA, Joint Commission, NCQA, OSHA, and Department of Health standards
• Support regulatory documentation, coding, billing, and quality initiatives

Required Qualifications
• Active RN State License
• BSN required
• BLS Certification required
• Minimum 5 years of Case Management/Utilization Review RN experience
• Acute hospital experience required
• Experience in Long-Term Acute Care (LTAC), Rehab, or Skilled Nursing preferred
• Epic EMR experience required
• Experience with InterQual and Milliman guidelines required