Case Manager II; RN or LVN

Department: HS - ICM

Employment Type: Full Time

Location: 1600 Corporate Center Dr., Monterey Park, CA 91754

Reporting To: Annie Lai

Compensation: $35.00 - $45.00 / hour

The Case Manager II is an experienced clinical case management professional responsible for independently managing a complex caseload across acute inpatient and post-acute settings. The role integrates concurrent clinical review, discharge and transition-of-care planning, direct Member and family engagement, and collaboration with hospitals, SNFs, Hospitalists, PCPs, specialists, health plans, and internal clinical teams. The Case Manager II applies sound clinical judgment, identifies barriers and high-risk needs, and coordinates services to support safe transitions, reduce avoidable utilization and readmissions, and improve continuity of care.

Compared with a Case Manager I, the Case Manager II is expected to demonstrate greater independence, ownership of complex cases and escalations, and contribution to market- and department-level initiatives

• Comply with Case Management, Utilization Management, health plan delegation, regulatory, and accreditation requirements applicable to assigned responsibilities.
• Independently manage a complex mixed caseload across acute inpatient, SNF, rehabilitation, and other post-acute settings, with timely follow-up and accurate documentation.
• Review medical records and other clinical documentation to assess medical necessity, appropriateness, level of care, skilled needs, and transition-of-care needs using MCG and other applicable criteria and guidelines.
• Coordinate required initial and concurrent clinical reviews and communicate relevant findings, barriers, and escalations to the Medical Director and Case Management leadership as appropriate.
• Collaborate with Hospitalists, facility Case Managers, discharge planners, PCPs, specialists, Members, families, and other care partners to establish and advance safe discharge plans as early as possible in the admission.
• Assess, plan, implement, coordinate, monitor, and evaluate care management interventions to support appropriate utilization, continuity of care, and reduction of avoidable ER utilization and hospital readmissions.
• Conduct direct Member and family outreach to provide education, identify barriers, support discharge planning, and promote engagement in the transition-of-care plan.
• If designated, conduct onsite hospital and/or SNF visits, as assigned, to support Member engagement, facility collaboration, transition planning, and progression to the most appropriate level of care.
• Facilitate PCP and specialty follow-up and coordinate referrals to Population Health, Care at Home, disease management, high-risk care management, and other internal or community programs when appropriate.
• Identify high-risk Members, repeat utilizers, care gaps, and social or clinical barriers and coordinate appropriate interventions and escalation.
• Build and maintain collaborative relationships with health plans, hospitals, SNFs, Hospitalists, Medical Directors, provider offices, and other network partners.
• Communicate determinations and care coordination outcomes to providers and/or Members, as applicable, in accordance with state, federal, health plan, and accreditation requirements.
• Participate in Case Management rounds, facility meetings, network discussions, and performance-improvement initiatives on and off site as needed.
• Support implementation and refinement of Case Management workflows, particularly in developing or expanding markets, and serve as a clinical/operational resource to internal teams and external partners.
• Provide education, workflow support, and informal mentorship to Case Manager I staff and other team members as appropriate.
• Escalate complex clinical, operational, access, or provider issues appropriately and partner with leadership to drive resolution.
• Maintain timely, accurate, and complete documentation and reporting of Case Management activities, Member engagement, referrals, appointments, and identified barriers.
• Perform other duties and responsibilities as assigned consistent with the scope and level of the position.

• Active Registered Nurse (RN) or Licensed Vocational Nurse (LVN) license in the applicable state, in good standing.
• Minimum two (2) years of clinical experience as an RN/LVN.
• Demonstrated experience in Case Management, Utilization Management, acute care, post-acute care, or a related clinical setting.
• Strong…