Concurrent Review Nurse (RN), Non-Hospital
Ontario, CA 91761
Oversight of Concurrent and retrospective reviews for medical necessity, appropriateness of services and level of care. Review to ensure treatment plan is consistent with diagnosis. Collaborate with discharge planner and coordinator to ensure safe discharge, including referrals to internal partners, services, DME. Timely completion of denials. Review hospital requests for HLOC and LTAC Transfers.
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 Health Plan Members.
- 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 health plan 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.
- Possession of a high school diploma or equivalent.
- Two (2) or more years of utilization management experience in a health care delivery setting.
- Registered Nurse (RN) license issued by the California BRN (active, unrestricted, and unencumbered)
- Knowledge of evidence based clinically criteria and California Children Services (CCS).
- Valid California Driver s License
- Must have a high degree of patience.