RN Case Manager
Santa Monica, CA
Prodware Solutions LLC
5x8 hrs, Days

• First Time Traveler: No - Must have travel experience
• Ratios: 1:20-22
• Experience must be current acute hospital experience, will not accept candidates that have not worked in the role in the last 6 months.
• Weekend REQ: at least 2 in a 4-week schedule, to meet dept needs
• CA state license: Yes
• Pending License accepted: Yes
 

Job Summary

The Case Manager is responsible for coordinating patient care across the continuum of care to ensure high-quality, cost-effective outcomes. The role integrates clinical care coordination, utilization review, discharge planning, and resource management to support safe and timely transitions of care.

Working collaboratively with physicians, nurses, social workers, and interdisciplinary teams, the Case Manager evaluates patient needs, develops individualized care plans, facilitates discharge planning, and ensures compliance with regulatory and payer requirements.

Essential Responsibilities

Care Coordination

• Assess patient clinical status, psychosocial needs, and discharge planning requirements.
• Develop and implement individualized care plans in collaboration with physicians and the interdisciplinary care team.
• Coordinate services across departments and external care providers to ensure continuity of care.

Utilization Review

• Conduct medical necessity reviews using InterQual or Milliman criteria.
• Monitor patient progress and ensure appropriate level of care (inpatient, observation, outpatient).
• Collaborate with physicians regarding status changes when appropriate.

Discharge Planning

• Identify barriers to discharge and coordinate services to support safe patient transitions.
• Arrange post-acute services including home health, skilled nursing facilities, rehabilitation, or outpatient care.
• Provide patient and family education regarding care plans and discharge instructions.

Regulatory Compliance

• Ensure compliance with CMS, Joint Commission, and hospital regulatory standards.
• Maintain accurate documentation in the electronic medical record (EMR).
• Support hospital initiatives related to quality outcomes and readmission reduction.

Collaboration

• Participate in multidisciplinary rounds with physicians, nursing staff, and ancillary teams.
• Communicate patient care plans and discharge goals to all stakeholders.
• Work with payers and insurance providers to coordinate coverage and authorization when needed.

Required Qualifications

• Current California Registered Nurse (RN) license or pending license
• Bachelor of Science in Nursing (BSN) preferred
• Minimum 3–5 years of acute care clinical experience
• Experience with care coordination, utilization review, or discharge planning
• Knowledge of InterQual or Milliman guidelines
• Strong understanding of hospital workflows and clinical documentation

Preferred Qualifications

• Previous hospital case management experience
• Case Management certification (CCM, ACM, or similar)
• Experience with Epic electronic medical record system
• Experience working with complex patient populations

Skills & Competencies

• Admission Criteria (InterQual)(ED only)
• Experience with HMOs, IPAs, etc.
• Experience with Assessing patients, Care Coordination, and Discharge Planning
• 2-year acute care Hospital inpatient Case Manager experience performing
• Care Coordination and Admission Reviews

Physical Requirements

• Ability to work in a hospital clinical environment
• Frequent use of computer systems and electronic medical records
• Ability to participate in interdisciplinary rounds and patient consultations

Work Environment

The Case Manager works within an acute care hospital setting, collaborating with multidisciplinary teams including physicians, nurses, social workers, therapists, and external care providers to support patient outcomes and efficient resource utilization.