Integrated Transitional Care Nurse, RN 24-00168

Alura Workforce Solutions; Rancho Cucamonga (CA); Remote; USD 65,000 - 95,000; Full time

Job summary

An innovative healthcare organization is seeking an Integrated Transitional Care Nurse, RN to join their dynamic team. This role is pivotal in delivering quality healthcare to high-risk members through effective risk assessments and seamless transitions between care settings. You will collaborate with various stakeholders, ensuring compliance and addressing potential quality of care issues. With a focus on continuous improvement, this position offers the opportunity to make a significant impact in the lives of patients. If you're passionate about transforming healthcare and possess the necessary experience, this is the perfect opportunity for you.

Qualifications

• 2+ years of experience in Utilization Management/Case Management in acute or skilled nursing.
• Active RN license issued by the California BRN.

Responsibilities

• Conduct discharge risk assessments for high-risk Members.
• Collaborate with hospitals and IPAs for seamless transitions in care.
• Oversee compliance with regulatory documentation requirements.

Skills

Utilization Management

Case Management

Analytical Skills

Communication Skills

Interpersonal Skills

Organizational Skills

Education

Registered Nurse (RN) License

Tools

Electronic Medical Records (EMR)

Job description

Title

Integrated Transitional Care Nurse, RN (Managed Care Health Plan)

Position Type:

Remote

Schedule:

M-F, 8:00 am – 5:00 pm

Description

Join our dynamic team in the Integrated Transition Care Department! Under visionary leadership, you'll collaborate with hospitals and Independent Physician Associations to deliver continuous, quality healthcare to our high-risk Members. As the Integrated Transitional Nurse, RN, you'll lead risk assessments, oversee reviews, and ensure seamless transitions between care settings. Engage with various departments to identify outliers and ensure compliance. Serve as the liaison between stakeholders, contributing to effective communication and goal achievement. Join us and be part of revolutionizing transitional healthcare!

1. Conduct discharge risk assessments for high-risk/high-acuity Members.
2. Oversee and perform concurrent and retrospective reviews for medical necessity based on evidence-based criteria, including reviews via telephonic assessment, clinical documentation, and electronic medical records (EMR).
3. Ensure treatment plans align with diagnoses, performing initial reviews within 24 hours to meet admission criteria.
4. Collaborate with coordinators to facilitate timely transitions to appropriate care levels and assist with transfer orders.
5. Refer cases requiring clinical consultation to the medical director promptly.
6. Refer cases to Care Management, Behavioral Health, Health Education, Housing, and community health services as appropriate.
7. Identify outliers, document findings, and report on potential quality of care issues.
8. Complete denials processes timely, reviewing variances and consulting with the Medical Director as needed for approvals or denials.
9. Ensure compliance with regulatory documentation requirements.
10. Act as a liaison between hospitals, IPAs, vendors, outside agencies, and providers to ensure effective communication and collaboration.
11. Verify delivery of DME, coordinate hospital follow-ups, review medications, and address transportation needs.
12. Oversee discharge planning assessments.
13. Perform medication reconciliation based on patient acuity and medication types.
14. Follow up post-discharge to confirm attendance at follow-up appointments, initiate Health Home visits, and coordinate in-home visits if appropriate.
15. Coordinate additional follow-up with Behavioral Health & Care Management teams as needed.

Requirements

• At least two (2) years of Utilization Management / Case Management experience in an acute or skilled nursing setting, with emphasis on concurrent review and utilization management.
• Active, unrestricted Registered Nurse (RN) license issued by the California BRN.
• Valid California Driver's license and automobile insurance.
• Ability to qualify and maintain driving record standards for company vehicle use (no more than three points).
• Knowledge of evidence-based clinical criteria and California Children Services (CCS).
• Strong analytical, communication, interpersonal, and organizational skills.