The Case Management Nurse performs complicated case reviews and first level determination approvals for inpatient, outpatient, and ancillary services requests, exclusive to a State Health Plans population (e.g. Medi-Cal). Reviews include benefit determination, medical appropriateness, and medical necessity determination requiring considerable clinical judgment, independent analysis, critical-thinking skills, and detailed knowledge of departmental procedures and clinical guidelines. CM Nurse acts as liaison between the member/patient, the primary care provider, specialist(s), ancillary provider, and the designated Health Plan (e.g. Gold Coast Health Plan, Inc.) to promote appropriate and cost effective use of medical resources.

The position may require telephonic, web based, and onsite clinical reviews; therefore, the employee may need to use their private auto for travel to our various health centers, contracted hospitals, or other locations for offsite meetings.