- Full Time/Contract
- Case Management
- Rancho Cucamonga, CA
Our Client is a not-for-profit, rapidly growing Medi-Cal and Medicare health plan serving over 1,138,447 residents of the Riverside and San Bernardino counties. Our client maintains a Positive Team Culture as demonstrated by being voted by Los Angeles News Group readers as "Favorite Overall Company to Work For , "Favorite Training Program , and "Favorite Workplace Culture in their 2014 Winning Workplaces survey.
Concurrent Review – RN
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 an 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.
- 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 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 in a timely manner and per assigned rounds schedule.
- Responsible for identifying outliers and preparing documentation as well as reports on 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 in an effort 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.
- Any other duties as required to ensure Health Plan operations are successful.
- Ensure the privacy and security of PHI (Protected Health Information) as outlined in policies and procedures relating to HIPAA compliance.
QUALIFICATIONS / REQUIREMENTS
|Education/License:||Possession of a valid RN license issued by the State of California. Possession of a valid State of California driver’s license automobile insurance.|
|Experience:||Two or more years of utilization management/case management in a health care delivery setting, with an emphasis on Concurrent Review and utilization management.|
|Knowledge/Skills Required:||Self-starter and a team player. Responsible for the performance of concurrent and retrospective reviews for medical necessity and appropriateness of service and care. Knowledge of evidence based clinically criteria and California Children Services (CCS). Must have analytical skills, time management, and problem solving abilities. Must have a high degree of patience, excellent communication, interpersonal and organizational skills.|