Nurse Case Manager

Nurse Case Manager / Clinical Quality Reviewer MUST live in California Job Description This role focuses on reviewing and investigating potential quality of care issues arising from member grievances and internal referrals. You will apply your clinical expertise and critical thinking to assess potential quality problems, determine appropriate levels of review, and support provider performance improvement. The position combines clinical quality review, utilization review, and discharge planning oversight in a fully remote environment with occasional on-site presence if needed. Responsibilities Investigate and review potential quality of care issues (PQIs) arising from member grievances and internal referrals in accordance with department protocols. Analyze quality issues from both internal and external sources to identify patterns, trends, and opportunities for improvement. Apply critical thinking and clinical judgment to thoroughly assess whether quality of care concerns resulted in, or had the potential to result in, harm to members. Determine the appropriate level of case review, including when to escalate cases to a Medical Director, Peer Review Committee, or Credentialing Committee for final determination. Prepare detailed case summaries and documentation for presentation at physician committees as needed. Develop and prepare corrective action plan requests when providers need to implement changes to their current practice to address identified quality issues. Present and discuss corrective action plan responses with the Medical Director and/or Peer Review Committee to ensure appropriate follow-up and monitoring. Manage an assigned case load to meet all timeliness requirements and performance expectations. Perform prospective, concurrent, and retrospective utilization reviews and first-level determination approvals for members using evidence-based guidelines, including BSC and CMS guidelines and nationally recognized clinical criteria for Medicare lines of business. Conduct clinical review of claims to assess medical necessity, coding accuracy, medical policy compliance, and contract compliance. Ensure discharge planning at levels of care appropriate for member needs and acuity, including determining post-acute needs such as levels of care, durable medical equipment, and post-service needs to support quality and cost-appropriate discharge plans. Prepare and present cases to the Medical Director for oversight and medical necessity determinations, and communicate determinations to providers and/or members in compliance with state, federal, and accreditation requirements. Develop and review member-centered documentation and correspondence that accurately reflect determinations and comply with regulatory and accreditation standards. Identify potential quality of care issues, service delays, or treatment delays and intervene as clinically appropriate. Refer members to Case Management when there are acute inpatient needs that may affect discharge planning. Attend staff meetings, clinical rounds, and weekly huddles to collaborate with colleagues and stay aligned with departmental processes and updates. Maintain required quality and productivity metrics for all assigned casework. Serve as a buddy or support resource for new employees, helping them integrate into workflows and processes. Maintain a HIPAA-compliant workspace in a telework environment and adhere to all privacy and security requirements. Utilize electronic medical records (EMR) and clinical criteria tools such as MCG to support utilization management and clinical decision-making. Essential Skills Current and active California Registered Nurse (RN) license. At least 5 years of prior relevant clinical or utilization management experience. Strong background in acute care and inpatient care settings. Experience providing direct patient care and applying clinical judgment in complex situations. Proficiency in performing prospective, concurrent, and retrospective utilization reviews. Ability to conduct first-level determination approvals using BSC and CMS evidence-based guidelines, policies, and nationally recognized clinical criteria for Medicare lines of business. Demonstrated experience in clinical review of claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance. Strong communication skills, including the ability to present cases and discuss determinations with providers, committees, and internal stakeholders. Strong computer skills and navigation abilities, including use of EMR systems and clinical criteria tools such as MCG. Ability to ensure appropriate discharge planning and post-acute care arrangements based on member needs and acuity. Capability to develop and review member-centered documentation and correspondence that meets regulatory and accreditation standards. Proven ability to identify potential quality of care issues and intervene as clinically appropriate. Demonstrated ability to maintain quality and productivity metrics in a case management or utilization review environment. Independent motivation, strong organizational skills, and the ability to manage a telework workload effectively. Ability to maintain a HIPAA-compliant workspace and uphold privacy and confidentiality standards. Additional Skills & Qualifications Bachelor of Science in Nursing (BSN) or an advanced nursing degree is preferred. Experience in utilization management and utilization review in a health plan or similar setting. Familiarity with MCG criteria and other nationally recognized clinical guidelines. Experience working with Medicare populations and understanding of BSC and CMS guidelines and policies. Strong teamwork and collaboration skills, with a desire to work closely with interdisciplinary teams. Experience preparing cases for physician committees, peer review, or credentialing processes. Experience developing and monitoring corrective action plans for providers. Ability to serve as a mentor, buddy, or support resource for new employees. Comfort working in a remote environment while occasionally reporting to a local office if needed for IT or operational reasons. Work Environment This position operates primarily in a fully remote telework environment, with standard hours Monday through Friday, typically between 8:00 a.m. and 5:00 p.m. You will work in a home-based setting and must maintain a HIPAA-compliant workspace to protect member privacy and confidentiality. While the role is remote, you must be open to occasionally going into the nearest office if needed, such as for rare internet or IT issues or specific business needs. The role involves extensive use of computers, electronic medical records (EMR), and clinical criteria tools such as MCG, as well as regular participation in virtual staff meetings, clinical rounds, and weekly huddles. The work environment emphasizes collaboration, continuous quality improvement, and adherence to regulatory and accreditation standards, while offering the flexibility of remote work Job Type & Location This is a Contract to Hire position based out of Rancho Cordova, CA. Pay and Benefits The pay range for this position is $45.00 - $55.00/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 Aug 8, 2026. 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 20,000 consultants and 5,000 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500. We are proud to be an Engineering News-Record (ENR) Top 500 Design Firm for our engineering design services and a ClearlyRated Best of Staffing® winner for both client and talent service. 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 process due to a disability, please email [email protected] for other accommodation options. San Francisco Fair Chance Ordinance: Pursuant to the San Francisco Fair Chance Ordinance, for all positions located in the city and county of San Francisco, we will consider for employment qualified applicants with arrest and conviction records. Massachusetts Lie Detector: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability. Use of Artificial Intelligence (AI): We may use Artificial Intelligence (AI) to support parts of our hiring process, including sourcing, screening, and evaluating candidates. AI helps assess applications and qualifications, but final decisions are made by our hiring team. By applying, you acknowledge and agree that your application may be reviewed using AI tools.