Concurrent Review Nurse

Health Plan of San Joaquin/Mountain Valley Health Plan; Modesto (CA); Remote; USD 95,000 - 138,000; Full time

Job summary

A leading health care provider seeks a Concurrent Review Nurse to ensure member care is rendered at appropriate levels. The candidate will conduct reviews, collaborate with providers, and navigate complex regulations in a remote role. Strong clinical skills, RN licensure, and experience in a hospital setting are critical for success in this position.

Benefits

Competitive salary

Robust health/dental/vision insurance

Generous paid time off

CalPERS retirement pension

Employer-Paid Life Assistance Program

Education and training reimbursement

Qualifications

• At least 3 years clinical experience as an RN in a hospital or clinic.
• Unrestricted California Registered Nurse license required.
• Knowledge of concurrent review principles and managed care regulations.

Responsibilities

• Conducts concurrent review of inpatient activities, ensuring compliance with regulations.
• Collaborates with providers to resolve care issues and makes level of care recommendations.
• Documents activities accurately in HPSJ systems and compiles reports as needed.

Skills

Clinical Skills

Assessment and Analysis

Problem Solving

Interpersonal Skills

Time Management

Customer Service Skills

Education

Graduation from an accredited nursing school

California Registered Nurse license

Tools

Word

Excel

Job description

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Health Plan of San Joaquin/Mountain Valley Health Plan provided pay range

This range is provided by Health Plan of San Joaquin/Mountain Valley Health Plan. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

Base pay range

$95,370.00/yr - $137,850.00/yr

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

We are currently hiring a Concurrent Review Nurse to join our team!

Must reside in California - remote position.

What You Will Be Doing:

Under general supervision, conducts onsite and/or telephonic concurrent review of inpatient activities. In addition, this position is responsible for ensuring that member care is rendered at the most appropriate level, for the requisite length of time, in compliance with HPSJ, regulatory and contractual requirements. Work is varied and complex and requires a moderate amount of discretion and independent judgement.

• Confirms member care plan with provider.
• Identifies care issues and collaborates with provider to resolve; escalates as necessary.
• Makes timely and appropriate recommendations regarding transfers, determination of level of care and discharge planning.
• Escalates non-standard requests to Medical Director for review; approves or denies services as directed.
• Researches and resolves adjudication issues in an accurate and timely manner.
• Documents activities in appropriate HPSJ system(s) according to standards.
• Tracks data as required; compiles data for, produces and submits routine reports.
  
  

Required

What You Bring:

• Strong clinical skills as defined in California scope of practice guidelines for RN’s.
• Ability to read, interpret and apply complex written regulations, guidelines and other materials; ability to read and interpret clinical information.
• Produces work that is accurate and complete.
• Produces the appropriate amount of work.
• Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
• Rebounds from setbacks and adversity when facing difficult situations.
• Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
• Strong skills in assessment and analysis.
• Strong problem solving skills.
• Basic negotiation skills.
• Interpersonal skills - interacts effectively with individuals both inside and outside of HPSJ; relates openly and comfortably with diverse groups of people.
• Strong oral and written communication skills, with the ability to communicate professionally to diverse individuals inside and outside of HPSJ, effectively explain complex information, and document according to standards.
• Ability to use tact and diplomacy to diffuse emotional situations.
• Ability to work independently and as part of a team.
• Time management and organizational skills. Uses time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines.
• Strong customer service skills.
• Basic skills in Word and Excel.
• Ability to enter data into and navigate through multiple databases.
• Ability to speak and be understood in English.
• May require proficiency in one of HPSJ’s threshold languages (as defined by HPSJ’s Cultural and Linguistic Program).
• Ability to handle confidential information with appropriate discretion.
  
  

Required within six months of hire

• In-depth knowledge of the principles and practices of concurrent review.
• In-depth knowledge of government sponsored programs and regulations as they apply to concurrent review.
• In-depth knowledge of managed care principles, practices and regulations as they apply to concurrent review.
• In-depth knowledge of health care delivery systems as they apply to concurrent review.
  
  

Required

What you Have:

• Graduation from an accredited nursing school.
• At least three years clinical experience as an RN in a hospital or clinic.
  
  

Preferred

• Experience in case management, utilization management or discharge planning.
• Experience as a clinician in a managed care setting.
• Experience working with Medi-Cal and/or MediCare populations.
  
  

Licensure, Certification, Registration

• Unrestricted California Registered Nurse license.
• Valid California driver license and reliable transportation or, the ability to obtain transportation on demand in the counties served by HPSJ if prohibited from getting a driver license due to a medically documented disability.
  
  

HPSJ Perks:

What You Will Get:

• Competitive salary
• Robust and affordable health/dental/vision (90% paid medical for employees and 100% paid dental/vision for employees) with choices in providers
• Generous paid time off (starting at 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
• CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
• Two flexible spending accounts (FSAs)
• Employer-Paid Term Life and AD&D Insurance
• Employer-Paid Disability Insurance
• Employer-Paid Life Assistance Program
• Health Advocacy
• Supplemental medical, legal, identity theft protection
• Access to exclusive discount mall
• Education and training reimbursement in addition to employer-paid elective learning courses.
• A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
• A shorter commute – if you’re commuting from the Central Valley to the Bay Area.
• Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.
  
  

Our Vision:

Continuously improve the health of our community.

Our Mission:

We provide healthcare value and advance wellness through community partnerships.

We are an equal opportunity employer and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve. Employment decisions are made on the basis of qualifications and merit.

HPSJ provides equal employment opportunities to employees and applicants for employment and prohibits discrimination based on color, race, gender (including gender identity and gender expression), religion (including religious dress and grooming practices), marital status, registered domestic partner status, age, national origin (including language use) or ancestry, physical or mental disability, medical condition (including cancer and genetic characteristics), sex (including pregnancy, childbirth, breastfeeding or related medical condition), genetic information, sexual orientation, military or veteran status, political affiliation or any other characteristic made unlawful by applicable Federal, State or local laws. It also prohibits unlawful discrimination based on the perception that anyone has these characteristics, or is associated with anyone who has or is perceived to have these characteristics.

Important Notice: This job description is not a contract between HPSJ and the employee performing the job. The duties listed in the job description may be changed at the discretion of HPSJ, and HPSJ may request the employee to perform duties that are not listed on the job description.

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Hospitals and Health Care

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