Inpatient Clinical Nurse

Triple-S Management Corp.; San Juan (PR); On-site; USD 60,000 - 80,000; Full time

Job summary

Triple-S Management Corp. in Puerto Rico seeks a registered nurse to independently perform tasks under policies and guidelines, supporting inpatient program operations and audits.

The role emphasizes data collection, analysis, coordinating care, discharge planning, and collaboration with social workers to ensure timely, quality care for insured patients.

Qualifications

• Bachelor's Degree in Nursing required.
• 1–3 years clinical experience, preferable in hospital environment.
• Current/Active Nursing License in Puerto Rico.
• Member of College of Nursing Professionals of PR.

Responsibilities

• Visits participating hospitals and health centers to determine if records meet established clinical criteria guidelines for admissions and audits.
• Enrols assigned enrollees in the Inpatient Clinical Program.
• Documents the clinical review of each audit in the electronic system.
• Performs Admission Assessment within 72 hours of admission.
• Guides insured patients in the Inpatient Clinical Program with a multidisciplinary team.
• Coordinates services within 48 hours of discharge in safe, evidence-based care.
• Completes discharge assessments and schedules primary care follow-up.
• Reviews continued stay and discharge planning.
• Evaluates readmissions and related diagnoses.
• Collaborates with social workers and discharge planners.
• Identifies potential events for cost containment programs.
• Discusses adverse determinations with Medical Advisor/UR Manager and treating physicians.
• Notifies hospital of closed admission events and participates in weekend scheduling.

Skills

Nursing

Clinical documentation

Education

Bachelor's Degree in Nursing

Job description

At Triple-S, we are committed to providing meaningful job experiences for Valuable People (Gente Valiosa). We strive for excellence in everything we do, from the way we work together to the way we serve our customers.

When you join Triple-S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses.

JOB SUMMARY

Independently performs tasks guided by policies, clinical guidelines, and procedures. Selects the best methodology to achieve the outcomes identified in a work plan or project. Responsible for collecting inpatient data, analyzing and interpreting it, and making recommendations to be used by others at a higher hierarchical level for decision making.

ESSENTIAL FUNCTIONS

• Visits participating hospitals and health centers to determine if records meet established clinical criteria guidelines for admissions and any other required audits, documents relevant recommendations.
• Identifies assigned enrollees from the hospital census and enrolls them in the Inpatient Clinical Program.
• Documents the clinical review of each audit in the electronic system, meeting established quality standards.
• Performs Admission Assessment of all assigned patients during the first 72 working hours of admission to the hospital.
• Primary responsibility will be to provide guidance and support through an individualized plan to all insured persons admitted to the Inpatient Clinical Program with a multidisciplinary team.
• Ensures that all required services are coordinated on or before 48 hours of discharge in a safe and efficient manner in accordance with evidence-based clinical best practices.
• Completes discharge assessments for all assigned patients preferably on the same day of discharge or up to 24 hours after discharge and ensures coordination of primary care physician appointment 7 days after discharge.
• Review of continued stay, proactive discharge planning, transition of care for our patients.
• Evaluate readmissions to identify same or related diagnosis.
• Works directly with social worker and discharge planning to ensure coordination of services at discharge.
• Identifies and refers potential events to various cost containment programs, continuing to follow up on events as appropriate.
• Discusses adverse determination with the company Utilization Review Manager/Supervisor, Medical Advisor, Hospital Coordinator or Treating Physician.
• Notifies the Company Medical Advisor's final decision to the Hospital Coordinator or Treating Physician.
• Notifies hospital of closed admission events reviewed according to established process.
• Participates in the weekend scheduling program.

EDUCATION

• Bachelor's Degree in Nursing

EXPERIENCE

• Bachelor’s Degree (BD) in Nursing Sciences with one (1) to three (3) years of clinical experience, preferable in hospital environment.
• Current / Active License in Nursing without restrictions in Puerto Rico. Member of College of Nursing Professionals of PR.

COMPETENCIES

• Manages Ambiguity
• Action Oriented

It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, sex, gender identity, real or perceived sexual orientation, civil status, social condition, political ideologies, age, physical or mental disability, veteran status or any other characteristic protected by law. Drug-free company.

Equality Employment Opportunity/Affirmative Action for People with Disabilities/Veterans. Employer with E-Verify to verify the eligibility of employment of all the new employees.

We encourage Veterans and Disabled to Apply.