Utilization Management Lead — Inpatient Case Management (RN)
Core
Lead inpatient case management, status determination, and transitions of care for high-risk members in a California managed care environment.
Role type
Senior Utilization Management Lead (RN)
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), clinical assessment, data analysis, team leadership, stakeholder coordination
Preferred skills
Program scaling, audit preparation, HEDIS measures knowledge, bilingual English/Spanish
Technologies
EZCap, MCG
Responsibilities
Review and determine status for delegated inpatient and SNF admissions; manage post-discharge transitions and medication reconciliation; lead complex case management for high-risk members; refine risk stratification and documentation standards; build and coach case management team; prepare for health plan audits.
Seniority
Senior, hands-on IC with team leadership