Job Requisition ID: 10604
Position Summary/Position
Under the direction of the Supervisor, UM Inpatient & Specialty – CCA, the incumbent will work with Hospitals and Independent Physician Association (IPA) with their assigned Team Center to initiate coordinated and continuous cost-effective quality healthcare to ensure the continuity of the Member’s care needs are met timely throughout the admission and readmission prevention for our high-risk Members. This will be accomplished through concurrent review processes using nationally recognized criteria. The Integrated Transitional Care Nurse, RN – CCA will participate in providing transitional care services to the Members with each transition from one care setting to the next.
Major Functions (Duties and Responsibilities)
- Oversee and perform 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.
- Conduct reviews to ensure Member’s treatment plan is consistent with Diagnosis(es), specifically initial review within twenty-four (24) hours to ensure Members meet specified criteria for the respective admission(s).
- Work in collaboration with the coordinator to ensure timely arrangements for transitions to higher or lower level of care and assist with transfer orders as needed.
- Ensure the concurrent or retrospective review process includes referring cases that require clinical consultation with the medical director in a timely manner.
- Ensure cases are appropriately referred to Care Management, Behavioral health, Health Education, Housing, community health.
- Identify outliers and prepare documentation as well as report on potential quality of care issues as identified.
- Process timely completion of denials process per policy.
- Conduct timely compliance and completion of documents per regulatory requirements.
- Serve as the IEHP Liaison between hospitals, IPAs vendors, outside agencies and provider to ensure effective communication and collaboration in an effort to meet the Member’s treatment plan and goals.
- Oversee verification of delivery of ordered Durable Medical Equipment DME, Health Home visits, set up hospital follow up visits with PCP, review of Medications with Member and transportation needs.
- Oversee and complete discharge planning.
- Perform medication reconciliation based on acuity and type of medications.
- Generate additional follow up needed to assign to appropriate regional Behavioral Health & Care Management team.
- Any other duties as required ensuring Health Plan operations are successful.
Experience Qualifications
Two (2) or more years of Utilization Management / Case Management in a health care delivery setting in Acute or Skilled nursing, with an emphasis on Concurrent Review and Utilization Management. Experience with Commercial Plan Coverage required.
Education Qualifications
Associate’s degree in Nursing from an accredited institution required.
Professional Licenses
Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required.
Drivers License Required
Yes, must have a valid California Driver’s license and valid automobile insurance. Must qualify and maintain driving record to drive company vehicles based on IEHP insurance standards of no more than three (3) points.
Knowledge Requirement
Knowledge of evidence based clinical criteria and California Children Services (CCS). Knowledge of Commercial Managed Care coverage required.
Skills Requirement
Must have analytical skills. Excellent communication, interpersonal and organizational skills.
Abilities Requirement
Self-starter and a team player. Time management, and problem-solving abilities. Must have a high degree of patience.
Commitment to Team Culture
The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.
Work Model Location
Telecommute
A reasonable salary expectation is between $79,809.60 and $101,774.40, based upon experience and internal equity.
Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region, designated as “Great Place to Work.” With a provider network of more than 5,000 and a team of more than 3,000 employees, IEHP provides quality, accessible healthcare services to more than 1.5 million members. And our Mission, Vision, and Values help guide us in the development of innovative programs and the creation of an award-winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and make a difference with us! IEHP offers a competitive salary and stellar benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and state pension plan.
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