Join our Utilization Management team as an LVN Case Manager, a vital part of the Care Coordination team. You will engage in initial reviews, concurrent reviews, and discharge planning alongside the case management team. This role requires familiarity with CMS and MCG criteria, as case volume and complexity may vary daily. The minimum expectation is to process 15-20 inpatient cases per day, including initial reviews, follow-ups, and discharges.
ResponsibilitiesEnsure all post-discharge care is coordinated according to patient needs for continuity of care.Conduct inpatient and skilled nursing facility level of care reviews on a concurrent basis.Plan and coordinate all discharges from inpatient and skilled nursing facilities.Make outbound calls to the case management team to follow up on cases.Track barriers to appropriate inpatient and SNF utilization according to policy and procedure.Attend Utilization Management and/or Quality Management meetings as needed.Adjust patient's case management status based on medical status changes and progression of goals.
Essential SkillsExpertise in utilization review and prior authorization.Proficiency in care management, Medicare, and referral coordination.Experience with utilization management and Milliman Criteria Guidelines.Knowledge of inpatient case management and InterQual standards.Familiarity with NCQA standards.
Additional Skills & QualificationsMust know MCG and CMS criteria.Experience working with provider offices.Experience in utilization management.Knowledge of both MediCal and Medicare.Experience with EZ-CAP is a plus.High School Diploma or GED required.LVN with CA License required.Bachelor of Science in Nursing or other clinical advanced degree preferred.1+ years of managed care and inpatient experience preferred.Understanding of nursing processes and case management for continuity of care.Ability to apply business rules, medical guidelines, and health plan benefits to authorization decision-making.
Work Environment
Work Monday to Friday from 8 am to 5 pm, with a 1-hour lunch. Some holidays and weekends may be required if necessary. This is a remote position.
Job Type & Location
This is a Contract position based out of Redlands, California.
Pay and Benefits
The pay range for this position is $29.00 - $37.00/hr.
Eligibility requirements apply to some benefits and may depend on your job
classification and length of employment. Benefits are subject to change and may be
subject to specific elections, plan, or program terms. If eligible, the benefits
available for this temporary role may include the following:
• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)
Workplace Type
This is a fully remote position.
Application Deadline
This position is anticipated to close on Sep 26, 2025.
About Actalent
Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.
The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email actalentaccommodation@actalentservices.com for other accommodation options.