What are the responsibilities and job description for the Case Manager (RN) position at Purple Hires Inc.?
Job Description:
We are seeking an experienced Case Manager with a strong background in Utilization Review, Case Management, and Discharge Planning to support inpatient hospital operations at Santa Clara Hospital. This is a 100% onsite role requiring the ability to independently manage utilization and care coordination workflows.
Collaborate with physicians, multidisciplinary teams, patients, families, and external providers to ensure appropriate level of care, safe transitions, and regulatory compliance.
Key Responsibilities:
Utilization Management
- Perform daily pre-admission, admission, and concurrent utilization reviews
- Apply InterQual? and/or MCG? criteria to determine medical necessity and level of care
- Assess readiness for discharge and continued stay
- Educate care teams on utilization and care coordination processes
Case Management & Discharge Planning
- Coordinate inpatient discharge planning and transitions of care
- Participate in multidisciplinary rounds and care planning discussions
- Arrange authorizations, transfers, and post-acute services
- Ensure continuity of care through clear documentation
Regulatory & Compliance
- Ensure compliance with CMS, DMHC, NCQA, TJC, HIPAA, ERISA, EMTALA
- Accurately interpret and apply member healthcare benefits
Education & Experience:
- Minimum 2 years of inpatient utilization management, case management, or discharge planning experience
- Acute inpatient hospital experience required