Oct 14, 2021

Care Manager RN - Utilization Review

  • Providence
  • Napa, CA, USA

Job Description

We are looking for a Care Manager RN for the Utilization Review Department at Queen of the Valley Medical Center.

Location: Napa, CA

Work Schedule: On Call / Per Diem

Shift: 8-hour, Days

Job Summary:

The RN Case Manager is responsible for carrying out effective case management functions for identified patients by planning, coordinating, negotiating, procuring and managing the care and needs of complex patients and their families throughout the continuum of care. The RN Case Manager assists patients in the utilization of appropriate health care services. Position may require Utilization Management and Discharge Planning, Chronic Disease Case Management based on inpatient settings.

Essential Functions:

  • Manages assigned caseload of high risk patients by working with the patient and family to develop a discharge plan utilizing identified needs, medical necessity criteria, and payor and/or managed care principals including hospital discharge planning as needed.
  • Collaborates with physician and interdisciplinary team to develop an optimal plan for treatment that meets the medical, psychosocial and financial needs of the individual. Reassesses and modifies the discharge plan as necessary.
  • Advocates to assist and support the patient and family through the continuum of care by communicating with the interdisciplinary team and including the health plan where appropriate.
  • Utilizes knowledge of community resources, payor requirements, Medicare, Medi-Cal and other contractual requirements.
  • Maintains a professional appearance at all times. Observes the QVMC and departmental dress codes, wears an ID badge and optional professional white lab coat.
  • Actively participates in organizational decision making groups such as nursing committees, councils, or task force teams (for example - shared governance and/or core councils) as requested.
  • Together with the patient, family/caregiver, and in collaboration with the social worker, coordinates and establishes goals to be accomplished to meet identified needs. Implements solutions and evaluates patient outcomes toward goals and revises plan as indicated.
  • Completes an initial discharge planning assessment in the electronic medical record on all patients that meet the departmental high risk indicators.
  • Maintains competency in current utilization review software. Conducts utilization review utilizing Milliman Care Web QI effectively to support admission status, determine length of stay and to assist with facilitation of the discharge plan.
  • Maintains competency in current case management software. Completes referrals, utilizes electronic faxing and readmission documentation. Ensures payor authorization documentation, as needed, for extended stays and completes avoidable day documentation.
  • Documents utilization management reviews according to Utilization Management Guidelines including admission/concurrent and retrospective reviews for commercial and government payors.

Skills :

  • Exceptional communication and interpersonal skills.
  • Competent nursing assessment skills.
  • Sensitivity to the needs and situations of a multi-cultural population from a variety of income levels.
  • Strong organizational skills and ability to effectively present written and verbal information.
  • Proficiency with computers and telecommunication devices, such as smart phones.
  • Application of safety principles when performing duties.
  • Demonstrates ability to maintain fiscal responsibility in service utilization.
  • Ability to perform duties and responsibilities in an independent manner with little direct supervision, and complete job duties and responsibilities in a timely, accurate, thorough manner.
  • Models professionalism through effective time management, efficiency and a positive team approach.
  • Flexibility and an ability to adapt to changing and evolving hospital and departmental priorities.
  • Preferred: Bilingual (English/Spanish)

Minimum Position Qualifications:

Education :

  • Bachelor's Degree
  • Coursework/Training - Recent completion of a post-graduate level curriculum focusing on case management or
  • Current clinical experience with 2 years clinical experience in an acute care hospital setting, or
  • 1 year current experience in an inpatient or outpatient case management setting.


  • Current California RN license.
  • Current California Driver's License.

Preferred Position Qualifications:

Education : Bachelor's Degree in Nursing.

Experience : Case management, discharge planning, or utilization management experience in the acute, sub-acute, home health setting or managed care environment.

License/Certification: CCM or ACM Case Management certification

For 50 years, Queen of the Valley Medical Center has been the premiere medical facility in the Napa Valley. Our long history of providing high quality and caring service is founded on four core values: Compassion, Dignity, Justice, Excellence and Integrity. These central principles inspire us to reach out to those in need and to help heal the whole person-mind, body and spirit.

Queen of the Valley Medical Center combines the region's most qualified physicians and staff with the most advanced technology available. Because we have such high standards of care, our programs have been recognized regionally and nationally for their demonstrated success of outcome and care which is par with university hospitals.

Queen of the Valley Medical Center provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, Queen of the Valley Medical Center complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

Positions specified as "on call/per diem" refers to employment consisting of shifts scheduled on as "as needed basis" to fill in for staff vacancies.

Company: Queen of the Valley Medical Center

Category: Case Management

Req ID: R334342