Our client is a large Managed Care Provider in the Inland Empire. This is an ideal position for a Registered Nurse who is looking to work outside of a hospital setting, for an organization that prides itself on taking care of its employees, and has an amazing culture!
Under the direction of the Inpatient Review Nurse Manager and Supervisor, the incumbent will work with hospitals and IPAs, in collaboration with their assigned Team Center, that may include a Discharge Planner and Inpatient Coordinator, to initiate coordinated and continuous cost-effective quality healthcare to ensure the continuity of the Member’s care needs are met timely and readmission prevention is anticipated for Members.
Major Functions (Duties and Responsibilities):
- Responsible for the oversight of concurrent and retrospective reviews for medical necessity per evidenced-based criteria, appropriateness of service and level of care, either through telephonic review, clinical documentation submitted by respective facilities and/or electronic medical records (EMR) access.
- Responsible for conducting reviews to ensure that Member’s treatment plan is consistent with diagnosis(es), specifically initial review within 24 hours to ensure Member’s meet specified criteria for the respective admission.
- Responsible for working in collaboration with the Discharge Planner and Inpatient Coordinator to ensure timely arrangements for transitions to a higher or lower level of care and assist with transfer orders as needed.
- Responsible for oversight of authorizations for outpatient services or ancillary services as ordered, in preparation for the Member’s discharge in collaboration with Discharge Planner
- Responsible for providing oversight and ensuring that the concurrent or retrospective review process includes referring Members to Health Management, Health Education, Care Management, Behavioral Health or other internal or external programs as needed in collaboration with Discharge Planner.
- Responsible for ensuring that the concurrent or retrospective review process includes referring cases that require clinical consultation with the Medical Director promptly and per assigned rounds schedule.
- Responsible for identifying outliers and preparing documentation as well as reports on the potential quality of care issues as identified.
- Responsible for timely completion of denials process per policy.
- Responsible for timely compliance and completion of documents as required by regulatory requirements.
- Serve as the liaison between hospitals, IPAs, vendors, outside agencies, and providers to ensure effective communication and collaboration to meet the Members treatment plan and goals.
- Responsible for working with other Team Members, departments, IPAs and the facilities to support the goals of the department as well as strategic priorities and vision of the organization.
- Two or more years of utilization management/case management in a health care delivery setting, with an emphasis on Concurrent Review and utilization management.
- High school diploma or GED and Possession of an Active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN
- Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN.
- Knowledge of evidence-based clinical criteria and California Children Services (CCS).