Concurrent Review Registered Nurse

• Manage and coordinate in-patient review and discharge planning and case management activities related to immediate post-discharge needs.
• Train in and implement Care Transitions model in discharge planning; participate in diffusion of model in clinic setting.
• Support proactive hospital discharge planning, transfers, and redirection.
• Proactively and collaboratively, interface with medical director, HMO’s, clinic and facility staff, outside agencies, member and their families to assist in expediting appropriate discharge and coordination of care.
• Meet departmental review and documentation standards for work assignments.
• Write denial letters, and other Notices of Action, to member/providers using HMO templates.
• Serve as a liaison between hospital, clinics, health plan, vendors, outside agencies, and providers.
• Work with health plans on special requests such as obtaining ancillary services from non-contracting providers.
• Assist UM Director in the periodic review and update of UM/Case Management policy and procedures, and in the ongoing evaluation and improvement of workflow systems for UM.
• Coordinate completion and send required UM monthly reports to Health Plans, as assigned.
• Participates in Case Management committee meetings as well as outreach activities, agency advocacy, and serves on ad hoc committees, as requested.

• Utilization Management and Case Management experience
• Understanding and knowledge of healthcare benefits associated with various business lines (Medi-Cal, Medicare, Commercial).
• Inpatient concurrent review, especially working with complex medical patients, including aged, blind, disabled.
• Sound decision-making skills including problem solving, critical thinking, and good clinical judgment for clinical and non-clinical issues.
• Logical, independent thinker.
• 1 year Utilization Management in hospital, HMO, or IPA setting.
• 1 year in health care delivery setting at hospital, clinic or physician’s office

Hours for this Position:

• Day Time Monday – Friday 8:00 am-5:00pm

Salary:

80k to 90k per year