Utilization Management Jobs in Riverside, CA (NOW HIRING)

JOB SUMMARY

The Post-Acute Case Manager (LVN) performs concurrent and retrospective utilization review, care coordination, transition of care, and discharge planning activities for members across the continuum of post-acute care settings, including skilled nursing facilities (SNFs), long-term acute care hospitals (LTACHs), inpatient rehabilitation facilities (IRFs/ARUs), home health, hospice, assisted living, and select acute care settings. Working within a California-based healthcare Management Services Organization (MSO), this role supports the delivery of medically necessary, high-quality, and cost-effective care in compliance with applicable federal and state regulations, including CMS, Medi-Cal, and California Department of Managed Health Care (DMHC) requirements.

Under the direction of an RN, Medical Director, or other licensed clinical leader as required by California scope-of-practice laws, the Case Manager collaborates with providers, facilities, interdisciplinary teams, members, caregivers, and health plans to support appropriate level of care, length of stay management, discharge planning, prevention of avoidable readmissions, and safe transitions across the continuum of care.

MINIMUM & PREFERRED QUALIFICATIONS:

Education/Training

Minimum: High school diploma or GED equivalent required. Graduate of an accredited Licensed Vocational Nursing (LVN) program.

Preferred: Additional coursework or certifications in case management, utilization management, care coordination, or managed care preferred.

Experience

Minimum: At least Two (2) years of clinical experience in one or more of the following settings: post-acute care, skilled nursing, acute care hospital, rehabilitation, home health, hospice, utilization management, care coordination, or case management.

Preferred: Prior experience in an MSO, IPA, health plan, or Medi-Cal managed care setting.

Any combination of education and experience that provides the required knowledge, skills, and abilities may be considered.

Certification(s)

Active and unrestricted California Licensed Vocational Nurse license.

Skills, Knowledge & Abilities

· Working knowledge of utilization management, managed care principles, case management, discharge planning, and transition-of-care processes across the post-acute continuum.

· Knowledge of post-acute care settings and services, including skilled nursing facilities (SNFs), long-term acute care hospitals (LTACHs), inpatient rehabilitation facilities (IRFs/ARUs), home health, hospice, assisted living, and community-based care resources.

· Familiarity with CMS, Medi-Cal, DMHC, NCQA, Medicare Advantage, and California managed care regulatory requirements, including authorization and medical necessity review processes.

· Ability to apply approved clinical criteria, policies, guidelines, and established protocols within LVN scope of practice, including InterQual®, Milliman®, health plan guidelines, and internal utilization management standards.

· Understanding of care coordination, readmission prevention strategies, continuity of care practices, and appropriate level-of-care determinations.

· Ability to identify and escalate clinical, quality, psychosocial, discharge planning, and utilization concerns to appropriate clinical leadership.

· Strong organizational, analytical, documentation, and time-management skills with the ability to prioritize and manage multiple cases and competing deadlines in a fast-paced healthcare environment.

· Ability to coordinate care effectively across multiple provider groups, facilities, interdisciplinary teams, health plans, and community resources.

· Clear and professional verbal and written communication skills with the ability to communicate effectively with providers, members, caregivers, facilities, leadership, and external partners.

· Proficiency with electronic medical records (EMR), utilization management and case management platforms, authorization systems, and Microsoft Office applications.

· Ability to maintain confidentiality and exercise sound judgment in handling protected health information and sensitive matters in compliance with HIPAA and organizational policies.

· Ability to work independently while also functioning collaboratively within an interdisciplinary managed care and post-acute care environment.

· Demonstrated adaptability, professionalism, and problem-solving skills in supporting operational, regulatory, and patient care coordination needs.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS:

The demands described below are representative of those required to perform the essential functions of this position, with or without reasonable accommodation. The role is primarily sedentary, with sitting required approximately 70% of the time. The employee may occasionally be required to stand, walk, bend, or lift items weighing up to 20 pounds. The position requires frequent use of computers, telephones, and written or electronic communication. Local travel to hospitals, skilled nursing facilities, or MSO offices may be required. The employee must be able to work effectively in office and healthcare facility environments.

PAY RANGE

$35.00 - $38.00 / hourly