Care Manager II (RN): HOI-Care Management

Job DescriptionPrimary Duties and Responsibilities The Care Manager (RN) utilizes clinical expertise, patient assessments, and insurance payer requirements to coordinate patients' needs through the continuum of care including post-acute care and discharge plans. This role includes reviewing clinician assessments and patients' financial, family and psychosocial support to justify hospitalization for clinical reviews. Duties include reviewing records to assess for appropriate admission status, level of care, payer source, and UR contracts to validate billing. Documents pertinent patient issues, contacts and discharge plans on medical reviews. Communicates with physicians and medical offices to confirm appropriate insurance authorizations are in place. Assists with providing proper justification for insurance appeals and denials as needed. QualificationsEducation and ExperienceFive years of clinical experience in an acute healthcare system environment. Experience in Interqual or Millennium Guidelines required. One year of experience in utilization review required. Experience with healthcare database systems. License RequiredRegistered Nurse (RN) license (BSN/MSN) License PreferredN/A Certifications RequiredN/A Certifications PreferredUtilization Review Care Management Clinical Nursing About UsHoag Memorial Hospital Presbyterian is a nonprofit regional health care delivery network in Orange County, California, consisting of three acute-care hospitals with sixteen urgent care centers, eleven health centers and a network of more than1,800 physicians, 100 allied health members, 8,000 employees, and 2,000 volunteers. More than 30,000 inpatients and 550,000 outpatients choose Hoag each year. For over 70 years, Hoag has delivered a level of personalized care that is unsurpassed among Orange County's health care providers. Since 1952, Hoag has served the local communities and continues its mission to provide the highest quality health care services through the core strategies of quality and service, people, physician partnerships, strategic growth, financial stewardship, community benefit and philanthropy. Hoag offers a comprehensive blend of health care services including six institutes providing specialized care in the areas of cancer, heart and vascular, neurosciences, women's health, orthopedics, and digestive health through our institutes. Hoag was the highest ranked hospital in Orange County in the 2024-2025 U.S. News &World Report, the only Orange County hospital ranked in the top 10 for California. The organization was ranked the #5 hospital in the Los Angeles Metro Area and the #10 hospital in California. To learn more about Hoag's awards and accreditations, visit: https://www.hoag.org/about-hoag/awards-accreditations/. Hoag is an Equal Opportunity Employer and prohibits discrimination and harassment of any kind. Hoag is committed to the principle of equal employment opportunity for all employees and providing employees with a work environment free of discrimination and harassment. Hoag hires a diverse group of people in a manner that allows them to reach their full potential in the pursuit of organizational objectives.