Case Management Nurse-Utilization Review - (Open & Promotional)

Job Description:

Case Management Nurse-Utilization Review - (Open & Promotional)

Description

Description

San Mateo Medical Center is currently seeking one Full-Time Case Management Nurse to focus on Utilization Review.

At San Mateo Medical Center, we are always seeking ways to enhance the already impressive services we offer. This dedication to excellence is reflected in the exceptional care we provide and the extraordinary professionals who provide it. Here, you will have the chance to develop your talents with a skilled team of people who actively support and encourage each other's success. If you are ready to open new doors for your career, join us today!

Exciting news! Candidates have the opportunity to receive a sign-on bonus of up to $30,000. First-time external new hires, or current staff promoted internally or from other County departments into a regular Clinical Nurse-Case Management position in San Mateo Medical Center (SMMC) may be eligible to receive a sign-on bonus of up to $30,000 (subject to discontinuation at any time). The sign-on bonus will be in 3 phases and will be prorated for part-time.

The Case Management Nurse -Utilization Review will manage patient admission and ongoing stay reviews for patients with chronic or complicated medical conditions and oversee appeals with third-party payors. The incumbent will be responsible for retrospective and concurrent Utilization Review activities and for monitoring order status accuracy, documentation, and clinical compliance, in accordance with State and Federal regulations. In conjunction with other members of the health care team, the Case Management Nurse is accountable for timely coordination of quality health care services to meet the patient's health care needs across the continuum of care. This position requires knowledge of the adult, and geriatric populations.

The ideal candidate will possess one or more of the following:

• At least two years of recent, direct, and proven experience in Nurse Case Management in an acute care setting or at least two years of acute care hospital nursing experience.
• At least two years of experience with industry published standard level of care (i.e. InterQual or Milliman, etc.).
• InterQual interpretation and application of health industry utilization review criteria
• Experience providing the full range of Case Management nursing duties and responsibilities
• Ability to conduct daily Utilization Reviews to assess whether patients meet medical necessity criteria
• Experience working with multi-disciplinary teams to collaborate on appropriate level of care based on Utilization Review outcomes
• A Basic Life Support (BLS) certificate.
• Experience working with diverse, underserved populations.

NOTE: The eligible list generated from this recruitment may be used to fill future extra-help, term, unclassified, and regular classified vacancies.

Examples Of Duties
Duties may include, but are not limited to, the following:

• Identify problem situations or patient care issues; analyze, interpret, advise and consult with staff and other health care professionals to ensure patient order status reflects the correct level of care.
• Conduct daily Utilization Reviews to assess whether patient meets medical necessity criteria. Collaborate with the Clinical Services Manager II and Physician Advisor to support accurate determinations.
• Communicate utilization review findings to the Attending Provider when patients do not meet medical necessity criteria
• Partner with the Attending Provider to review and determine the appropriate level of care based on Utilization Review outcomes.
• Interpret and modify the system of patient care delivered by evaluating and reviewing standard practices and initiating new procedures.
• Provide consultation and guidance to providers to understand and ensure appropriate care is provided based on patient level of care needs.
• Advise the nursing staff in the establishment and maintenance of records of treatments given and the related progress of each patient for the purpose of analyzing patterns, synthesizing actions and evaluating patient care plans.
• Resolve unusual or unique patient care problems or situations, which require analytical, interpretative and constructive thinking.
• Formulate and develop plans, procedures and program content designed to meet specifically identified training/educational needs of nursing staff.
• Formulate, and/or collaborate with other health care practitioners to identify relevant clinical problems and conduct research to bring about their resolution.
• Evaluate nursing research literature and own research findings for implementation and incorporation as appropriate, into patient care activities.
• Serve as role model and resource person for staff and members of the interdisciplinary team.
• Perform related duties as assigned.

Qualifications
Licensure/Certification:

• Possession of a California license as a Registered Nurse.

Additional Qualifications for Restricted Positions:
Specific qualifications are required beyond those specified above for the assignments listed below.

Case Management Nurse
Must have knowledge of and verifiable experience in initiating and coordinating complex discharge plans, appeals for acute days and clinical denials and criteria for lower-level license care. Must have experience with interpretation and application of health industry utilization review criteria. If designated for acute in-patient psychiatry, candidate must have knowledge and verifiable experience in psychiatric patient treatment trajectory and the respective utilization review criteria.

Knowledge of:

• Advanced principles and practices in specialty areas.
• Nurse Practice Act.
• Current nursing and related medical theory and skills necessary to administer nursing care within assigned clinical settings.
• Safety and infection control practices.
• Clinical systems, supplies and equipment.
• Modern principles, techniques, and procedures of nursing.
• Medical terminology.
• Use and maintenance of medical instruments and equipment.
• Use and effects of medicines.
• Public health principles.
• Health promotion and disease prevention.
• Medical research principles and practices.
• Principles of training and education.
• Lean principles and methodologies.
• Data abstraction and utilization.
• Basic statistics for reporting purposes.
• Report writing.
• Regulatory and accreditation requirements for assigned area.

Skill/Ability to:

• Provide leadership and direction to multi-disciplinary medical teams.
• Give direction to staff.
• Evaluate the work of others.
• Develop and present training and continuing education programs.
• Design, evaluate, construct and modify research models; carry out research and present findings.
• Perform the full range of nursing duties and responsibilities.
• Prepare clear and concise medical record documentation.
• Write articles for publication on areas of specialty.
• Identify problems or discrepancies and make suggestions for corrective actions.
• Teach and orient staff.
• Establish and maintain effective working relationships with patients and staff members.
• Communicate effectively.

Education and Experience:

• Associate Degree in Nursing with two years' clinical experience including one year in a clinical specialty area, or
• Baccalaureate Degree in Nursing or a health-related field with one year of clinical experience including six months in a clinical specialty area, or
• Master's degree in Nursing.

Application/Examination
Open and Promotional. Anyone may apply. Current County of San Mateo and County of San Mateo Superior Court of California employees with at least six months (1040 hours) of continuous service in a classified regular, probationary, extra-help/limited term positions prior to the final filing date will receive five points added to their final passing score on this examination.

The examination will consist of an interview (weight: 100%). Depending on the number of applicants an application appraisal of education and experience may be used in place of other examinations or a screening committee may select those applicants whose education and/or experience appear to best meet the needs of the position based solely on the information provided in the application materials. Because of this screening process, all applicants meeting the minimum qualifications are not guaranteed advancement through any subsequent phase of the examination. All examinations will be given in San Mateo County, California, and applicants must participate at their own expense.

IMPORTANT: Applications for this position will only be accepted online. If you are currently on the County's website, you may click the "Apply" button. If you are not on the County's website, please go to https://jobs.smcgov.org/ to apply. Responses to the Supplemental Questionnaire must be submitted in addition to the standard County employment application form. A resume will not be accepted as a substitute for the required application materials. Online applications must be received by the Human Resources Department before midnight on the final filing date.

TENTATIVE RECRUITMENT SCHEDULE
DEADLINE TO APPLY: Wednesday, April 22, 2026, by 11:59 PM PST
APPLICATION SCREENING: April 24, 2026
COMBINED PANEL/DEPARTMENTAL INTERVIEWS: May 12, 2026

About the County
San Mateo County is centrally located between San Francisco, San Jose, and the East Bay. With over 750,000 residents, San Mateo is one of the largest and most diverse counties in California and serves a multitude of culturally, ethnically, and linguistically diverse communities.

The County of San Mateo, as an employer, is committed to advancing equity to ensure that all employees are welcomed in a safe and inclusive environment. The County seeks to hire, support, and retain employees who reflect our diverse community. We encourage applicants with diverse backgrounds and lived experiences to apply. Eighty percent of employees surveyed stated that they would recommend the County as a great place to work.

The County of San Mateo is an equal opportunity employer committed to fostering diversity, equity, and inclusion at all levels.

Analyst: Carolyn Burns (040826) (Clinical Nurse - F011)

Salary:

$164,278.40 - $194,147.20 Annually