Senior PACE Resource Management Registered Nurse

Senior PACE Resource Management Registered Nurse Job Description

Posted Friday, July 10, 2026 at 10:00 AM

Position Summary:

Under the direct supervision of the Medical Director Resource Management, the Senior PACE Resource Management RN is responsible for all non‑acute resource management and associated care coordination activities on a retrospective and on‑going basis, reviewing claims for services and verifying the appropriateness of care. This position works directly with the PACE CMO or their designee to evaluate and monitor medical appropriateness, determinations and care coordination activities.

This position is responsible for developing an appropriate plan approved by the IDT and implementing resource management projects and interventions, which will have a direct impact on improved outcomes and cost containment for San Diego PACE participants.

Essential Functions of the Job:

• Performs retrospective reviews on all inpatient and facility services assessing for appropriateness and medical necessity of the treatment requests using nationally recognized guidelines (Inter Qual or other criteria adopted by San Diego PACE), tied in to claims.
• Performs prospective, initial, concurrent and retrospective reviews for medication utilization rates and costs, diagnostics/testing, referrals to specialists, durable medical equipment (DMEs), care giving hours and transportation utilization, assessing for appropriateness and medical necessity of the treatment requests using nationally recognized guidelines (Inter Qual or other criteria adopted by San Diego PACE).
• Assess care quality and clinical risk issues on a concurrent basis, reporting any recognized issues to the IDT, Quality Improvement Department, any other relevant teams and PACE CMO.
• Responsible for the proactive resource management of post‑acute and chronically ill patients with the objective of improving quality outcomes and mitigating costs.
• In conjunction with the CMO, evaluates individual cases and provides feedback as needed to San Diego PACE PCP’s and their respective IDT regarding participants ALF and homecare plans and available covered services including identifying alternative levels of care that may be covered.
• With input from Transitions of Care RN Case Managers (TOC), addresses barriers to discharge/transition at team meetings including IDT and specific facility or specialty‑based ones like SNF, ALF, Hospice.
• Participate proactively in identifying priority areas of resource management gaps, collect and analyze data, assist in determining root causes, all for the purpose of developing plans for solutions.
• Develops strong working relationships with outside contracted providers, PCP’s, IDT members, ensuring medically necessary and appropriate resource utilization.
• Coordinates an interdisciplinary approach to support continuity of care.
• Assess documentation of medical records for completeness and relationship to the treatment plan and identify gaps or barriers in treatment plans.
• Provides utilization management, and issuance of all appropriate authorizations for covered services as needed by members.
• Facilitate on‑going communication between staff and contracted providers to ensure authorizations are secured in a timely and efficient process.
• Coordinates clinical utilization reviews and reporting of highest utilization cases.
• Actively participates in the discussion and notification processes that result from the clinical utilization reviews with the facilities and service providers.
• Works closely with Quality Department and follows up on complaints, grievances and quality issues related to participant post‑acute or ALF level stays.
• Reviewing data and how predictive analytics may be emphasized to mitigate healthcare recidivism within 30 calendar days.
• Develop and monitor standard practices in care based on those who may benefit from a palliative‑hospice platform due to disease trajectory and prognosis.
• Accountability for relevant Key Performance Indicator’s (KPI’s) for Resource Management, including but not limited to obtaining information from Transitions of Care RN Case Managers, to synthesize the following: utilization rates per 100 participants per…