Utilization Management Lead — Inpatient Case Management (RN)
Core
Lead inpatient case management, status determination, transitions of care, and complex case management for high-risk members in a managed care environment.
Role type
Senior Utilization Management Lead (Inpatient Case Management)
Builds
Inpatient admission/discharge workflows, post-discharge transition protocols, and complex care plans for high-risk populations.
Domain
Healthcare / Managed Care / Utilization Management
Required skills
Inpatient utilization management, complex case management, transitions of care, care plan development, regulatory compliance (CMS/DMHC), data analysis, program scaling, team leadership, clinical assessment
Preferred skills
Program-level outcome ownership, delegated MSO/health plan environment experience, audit preparation, HEDIS ToC measures knowledge, EZCap system proficiency, bilingual English/Spanish
Technologies
EZCap, MCG
Responsibilities
Review and determine status for delegated inpatient and SNF admissions; own post-discharge follow-up and coordinate discharge planning; manage complex case caseload for high-risk members; scale program standards and policies; build team structure and coach staff; prepare for health plan audits and generate reports.
Seniority
Senior, hands-on IC with leadership responsibilities