RN Case Manager, Utilization Review
Ventura, California
Ventura County Medical Center

Job Opportunity: Case Manager (Registered Nurse)

Location: Ventura, California
Employment Type: Travel/Contract
Contract Length: 13 weeks

Job Description

• Immediate start available.
• Role focuses on Utilization Review (UR) with proficiency in MCG guidelines and thorough understanding of the 2 Midnight Rule.
• Perform concurrent review of patients using MCG guidelines.
• Educate physicians and healthcare team on patient status as appropriate.
• Enter information concurrently into the electronic medical record and update case management module to track and record outcomes.
• Participate in appeal processes as needed.
• Coordinate and facilitate concurrent Peer-to-Peer calls.
• Respond timely to payer requests for clinical reviews and complete verbal reviews as needed.
• Assist with denial management to improve department processes.
• Collaborate with case managers and payers to ensure authorizations are obtained and current.

Unit Details

• Average Daily Census: 180 patients.
• Patient Population: Adolescents through Geriatrics.
• Shift: Monday to Friday, 8:30 AM to 5:00 PM (5 days x 8 hours).
• Weekend Coverage: Every other weekend (4 weekend shifts in 4 weeks).
• Unit Systems: Cerner, SBAR communication method.

Required Qualifications

• Valid Registered Nurse (RN) license in California.
• Associate of Science in Nursing (ASN) or Associate Degree in Nursing (ADN).
• Minimum 3 years of Case Management experience, including experience within the last year.
• Utilization Review experience, including proficiency with InterQual guidelines.
• Basic Life Support (BLS) certification issued by the American Heart Association or American Red Cross.

Key Responsibilities

• Validate patient registration status with physician orders against medical necessity screening criteria.
• Apply evidence-based medical necessity screening criteria per Utilization Review plan.
• Perform admission, continued stay, and discharge reviews.
• Ensure appropriate level of care screening for bedded outpatient services requiring hospital admission.
• Provide clinical review to health plans as required.
• Notify medical physician advisor when patient condition does not meet admission or continued stay criteria.
• Adhere to regulatory procedures including MOON, IMM Discharge, Appeal/HINN, Code 44, Two Midnight Rule, and Inpatient Only Procedure.
• Communicate with payers to obtain authorization for inpatient stays when patient status changes.

Required Documentation & Compliance

• Government-issued photo ID (Driver’s License or State ID).
• Emergency Contact Form prior to start.
• E-Verify or attestation required.
• Background check within 1 year of start, updated annually (7-year search including SS trace, county searches, nationwide, sex offender, FACIS).
• EPLS/GSA/SAM and HHS/OIG checks prior to start and updated annually.
• California Medi-Cal exclusion check within 30 days prior to start.
• Physical exam within 1 year of start, updated annually.
• Negative TB test or chest X-ray within 12 months of start, updated annually.
• Required immunizations or titers: Measles (Rubeola), Mumps, Rubella, Hepatitis B, Varicella.
• 10-panel drug screen within 1 year of start, updated annually.
• Seasonal flu vaccination or approved medical/religious exemption with mask mandate during flu season.
• COVID vaccination required; declinations accepted.

Required Training & Competencies

• Completion of Ventura RN Competencies Presentation and Competency Validation prior to start.
• Advanced EKG exam with a passing score of 80% (78% for Peds/PICU units), with up to two attempts allowed.
• Annual completion of age-specific competency exams.
• Medication/Pharmacology competency exam with 80% passing score.
• Trauma education: 4 hours annually via Ventura Cornerstone Trauma Modules unless current trauma certification (TNCC or TCAR) is held.
• Crisis Prevention Institute (CPI) certification or Management of Assaultive Behavior (MAB) as placeholder if CPI is pending.
• Completion of Mandatory Compliance Training annually with QR code verification.
• New Employee Orientation Attestation and Confidentiality Agreement signed prior to start.
• Facility-specific documents including ID card/badge forms, TB questionnaire, annual handbook acknowledgment, and nursing assistant policies (if applicable).

References & History

• Two professional references required for travel, allied, or per diem acute care roles (within 3 years of start).
• One professional reference required for per diem non-acute care roles.

Additional Notes

• Prior travel experience is not explicitly required for this position.
• The role requires strong knowledge of utilization review processes and regulatory compliance.
• Collaboration and communication skills with physicians, payers, and healthcare teams are essential.

This position offers a structured weekday schedule with every other weekend coverage, serving a diverse patient population in a hospital setting. It is ideal for experienced acute care case managers with strong utilization review expertise.