Inpatient Review Nurse, California RN/LVN License Required

. Perform reviews of inpatients with complex medical and social problems .

Posted 10/15/2026full-timeRemote • United StatesJuniorMid-Level💰 $77,905 - $116,858 per yearWebsite

Key responsibilities & impact

Perform reviews of inpatients with complex medical and social problems
Generate referrals to contracted ancillary service providers and community agencies with the agreement of the patient’s primary care physician
Perform follow-up reviews and evaluations in ambulatory care or lower-level-of-care settings
Review inpatient admissions timely and identify appropriate level of care and continued stay using evidence-based guidelines
Communicate with patients, families, and support systems and collaborate with physicians and ancillary service providers to coordinate care
Identify members needing complex or chronic case management after discharge and provide warm handoffs
Collaborate with IPA/MG for effective member management
Assign and provide daily oversight of the CCIP Coordinator’s activities and tasks
Record communications in EZ-Cap and/or the case management database
Arrange and participate in multidisciplinary patient care conferences or rounds
Monitor, document, and report pertinent clinical criteria according to UM policy and procedure
Monitor for overutilization or underutilization
Generate referrals to the Quality Management department as appropriate
Enter data for case management reports
Report progress of open cases to the Medical Director, Director of Healthcare Services, and Manager of Utilization Management
Perform other duties as assigned

What you’ll need

Minimum 3 years of general case management skills
Minimum 2 years of experience utilizing Milliman Care Guidelines to justify inpatient versus observation length of stay, including review of diagnosis and length of stay
Two consecutive years of related experience in a managed care setting as an inpatient case manager
Successful completion of an accredited Licensed Vocational Nursing Program
Active, valid, and unrestricted LVN or RN license in California (Non-Compact)
Must be willing to obtain LVN and/or RN licensure in Nevada, Arizona, North Carolina, and Texas immediately upon hire
Ability to communicate positively, professionally, and effectively; provide leadership, teach, and collaborate
Excellent critical thinking skills related to nursing utilization review
Knowledge of Medicare Managed Care Plans
Effective written and oral communication skills and ability to maintain constructive relationships with diverse members, management, employees, and vendors
Ability to perform mathematical calculations and calculate simple statistics
Ability to prioritize multiple tasks and apply advanced problem-solving and reasoning
Effective problem-solving, organizational, and time management skills
Ability to work in a fast-paced environment
Ability to comprehend and analyze statistical reports

Comp & perks

Licensure reimbursement for LVN and/or RN licensure in Nevada, Arizona, North Carolina, and Texas