Inpatient Review Nurse (Remote | California RN/LVN License Required | Part-Time | Weekends | Pacific Time Schedule)

Schedule

• Every Saturday and Sunday (required)
• Option A: 7:00 AM - 4:00 PM Pacific Time
• Option B: 11:00 AM - 7:00 PM Pacific Time

Responsibilities

• Performs reviews of inpatients with complex medical and social problems.
• Generates referrals to contracted ancillary service providers and community agencies with the agreement of the patient's primary care physician.
• Performs follow-up reviews and evaluations of patients in the ambulatory care or lower level of care setting.
• Reviews inpatient admissions timely and identifies appropriate level of care and continued stay based on acceptable evidence-based guidelines used by AHC.
• Effectively communicates with patients, their families and or support systems, and collaborates with physicians and ancillary service providers to coordinate care activities.
• Identifies Members who may need complex or chronic case management post discharge and warm handoff to appropriate staff for ambulatory follow up, as necessary.
• Communicates and collaborates with IPA/MG as necessary for effective management of Members.
• Assigns and provides daily oversight of the activities and tasks of the CCIP Coordinator.
• Records communications in EZ-Cap and/or case management database.
• Arranges and participates in multi-disciplinary patient care conferences or rounds.
• Monitors, documents, and reports pertinent clinical criteria as established per UM policy and procedure.
• Monitors for any over utilization or underutilization activities.
• Generates referrals as appropriate to the QM department.
• Enters data as necessary for the generation of reports related to case management.
• Reports the progress of all open cases to the Medical Director, Director of Healthcare Services and Manager of Utilization Management.
• Performs other duties as assigned.

Experience

Required:

• Minimum 3 years of general case management skills.
• Minimum of two years of experience utilizing Milliman Care Guidelines to justify Inpatient versus Observation Length of stay: including review of diagnosis and length of stay.
• Two consecutive years related experience in a managed care setting as an inpatient case manager.

Preferred:

• Experience with a Senior population.

Qualifications

Education Required:

• Successful completion of an accredited Licensed Vocational Nursing Program.

Education Preferred:

• Associates or Bachelors Degree.

Specialized Skills Required:

• Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
• Excellent critical thinking skills related to nursing utilization review.
• Knowledge of Medicare Managed Care Plans.
• Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors.
• Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly.
• Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Report Analysis Skills: Comprehend and analyze statistical reports.

Preferred:

• Knowledge and experience in complex/catastrophic case management preferred.

Licensure Required:

• Must have and maintain an active, valid, and unrestricted LVN or RN license in California (Non-Compact).
• Immediately upon hire, must be willing to obtain LVN and / or RN licensure in Nevada, (Non-compact), Arizona (Compact), North Carolina (Compact), and Texas (Compact) which will be reimbursed by company.

Pay

$77,905.00 - $116,858.00