Case Manager EX - Utilization Management in United States Embassy at Jobgether

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Case Manager EX - Utilization Management based in United States.

This role offers the opportunity to support high-quality patient care by ensuring effective utilization of healthcare resources across a leading academic health system.
The Case Manager will evaluate clinical services, coordinate care processes, and help improve outcomes through data-driven utilization management practices.
You will collaborate closely with physicians, clinical teams, and operational stakeholders to promote appropriate care delivery.
The position plays a key role in identifying utilization trends, supporting documentation quality, and reducing barriers within the patient care journey.
This opportunity is ideal for a nursing professional who combines clinical expertise with strong analytical and communication skills.
You will contribute to a mission-driven environment focused on innovation, research, education, and exceptional patient care.

The Case Manager will be responsible for managing utilization review activities, coordinating resources, and supporting quality improvement initiatives across the healthcare system. This role requires strong clinical judgment, attention to detail, and collaboration with multidisciplinary teams to ensure appropriate patient care and accurate documentation.

• Implement utilization management processes for hospitalized patients, reviewing admissions and ongoing care needs.
• Monitor and coordinate healthcare resource utilization while evaluating services provided across the health system.
• Perform utilization reviews using approved clinical decision support criteria, including severity and intensity-of-service guidelines.
• Analyze utilization patterns, trends, and clinical data to support operational improvements and quality initiatives.
• Participate in denial management activities, audits, special studies, and utilization monitoring projects.
• Review medical records and collaborate with physicians to improve clinical documentation accuracy and ensure patient conditions are properly reflected.
• Support initiatives that enhance care quality, compliance, and efficient healthcare delivery.
• Maintain accurate documentation and reporting related to utilization management activities.
• Build effective working relationships with physicians, nurses, administrative teams, and other healthcare professionals.
• Contribute to process improvement efforts that support patient outcomes and organizational goals.

The ideal candidate is an experienced nursing professional with a strong understanding of clinical care, utilization management practices, and healthcare compliance requirements. They should be able to manage multiple priorities while communicating effectively with diverse healthcare teams.

• Current Registered Nurse (RN) license required.
• Bachelor of Science in Nursing (BSN) required for external candidates.
• Minimum of 5 years of clinical experience and at least 1 year of case management experience preferred.
• Strong understanding of patient acuity levels and clinical documentation requirements.
• Knowledge of utilization management practices and healthcare regulatory standards, including Joint Commission, CMS, CDPH, and CCS requirements.
• Excellent written and verbal communication skills in English.
• Strong customer service skills and ability to collaborate effectively with multidisciplinary teams.
• Proficiency with computer systems and software, including Microsoft Office applications such as Word, Excel, PowerPoint, and Outlook.
• Ability to manage multiple projects and maintain productivity in a fast-paced healthcare environment.
• Strong analytical, organizational, and problem-solving skills.
• Ability to establish and maintain effective professional relationships across healthcare departments.
• Familiarity with California Children’s Services (CCS) authorization processes is preferred.
• CCM or ACM certification is preferred.
• Bilingual skills are a plus.

The company offers a comprehensive benefits package designed to support employees’ health, financial security, and overall well-being.

• Medical insurance coverage.
• Retirement savings plans.
• Paid sick leave and vacation time.
• Access to employee discounts and wellness programs.
• Opportunities to work within a leading academic healthcare environment.
• Professional development opportunities and continued learning support.
• A collaborative workplace focused on patient care, innovation, research, and education.