Integrated Transitional Care Nurse, RN 24-00168

Alura Workforce Solutions; Rancho Cucamonga (CA); Remote; USD 80,000 - 100,000; Full time

Job summary

Join a dynamic team as an Integrated Transitional Care Nurse, RN, where you'll lead risk assessments and ensure seamless transitions in healthcare for high-risk members. Collaborate with various departments to enhance quality care and compliance. This remote position offers a chance to make a significant impact in transitional healthcare.

Qualifications

• Two or more years in Utilization Management / Case Management.
• Active California RN license required.

Responsibilities

• Conduct risk assessments for high-risk members.
• Oversee reviews for medical necessity and appropriateness of service.
• Serve as liaison between hospitals and providers.

Skills

Analytical Skills

Communication

Interpersonal Skills

Organizational Skills

Education

Registered Nurse (RN) License

Job description

Integrated Transitional Care Nurse, RN 24-00168

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Integrated Transitional Care Nurse, RN 24-00168

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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. Dive into collaboration with various departments, identifying outliers, and ensuring compliance. Be the liaison between stakeholders, contributing to effective communication and goal achievement. Join us and be a part of revolutionizing transitional healthcare!

• Conduct Integrated Transition Care discharge risk assessment for high risk/ high acuity Members.
• Oversee and perform concurrent and retrospective reviews for medical necessity per evidenced based criteria, appropriateness of service and level of care, either through Telephonic review, clinical documentation submitted by respective facilities and/or electronic medical records (EMR) access.
• Conduct reviews to ensure Member's treatment plan is consistent with Diagnosis(es), specifically initial review within twenty-four (24) hours to ensure Members meet specified criteria for the respective admission(s).
• Work in collaboration with the coordinator to ensure timely arrangements for transitions to higher or lower level of care and assist with transfer orders as needed.
• Ensure the concurrent or retrospective review process include referring cases that require clinical consultation with the medical director in a timely manner.
• Ensure cases are appropriately referred to Care Management, Behavioral health, Health Education, Housing, community health.
• Identify outliers and prepare documentation as well as report on potential quality of care issues as identified.
• Process timely completion of denials process per policy. The RN will review variances in cases followed by an LVN for possible consultation with the Medical Director to determine approval for due to medical necessity or denial of days.
• Conduct timely compliance and completion of documents per regulatory requirements.
• Serve as the company Liaison between hospitals, IPAs vendors, outside agencies and provider to ensure effective communication and collaboration to meet the Member's treatment plan and goals.
• Oversee verification of delivery of ordered Durable Medical Equipment (DME), Health Home visits, set up hospital follow up visits with PCP, review of Medications with Member and transportation needs.
• Oversee and complete Discharge planning assessment.
• Perform medication reconciliation based on acuity and type of medications.
• Outreach to Member post discharge to ensure Member attended follow up appointment, Health Home starts visits, possible in-home visit by RN or assigned LCSW as appropriate.
• Generate additional follow up needed to assign to appropriate regional Behavioral Health & Care Management team.
  
  

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. Dive into collaboration with various departments, identifying outliers, and ensuring compliance. Be the liaison between stakeholders, contributing to effective communication and goal achievement. Join us and be a part of revolutionizing transitional healthcare!

• Conduct Integrated Transition Care discharge risk assessment for high risk/ high acuity Members.
• Oversee and perform concurrent and retrospective reviews for medical necessity per evidenced based criteria, appropriateness of service and level of care, either through Telephonic review, clinical documentation submitted by respective facilities and/or electronic medical records (EMR) access.
• Conduct reviews to ensure Member's treatment plan is consistent with Diagnosis(es), specifically initial review within twenty-four (24) hours to ensure Members meet specified criteria for the respective admission(s).
• Work in collaboration with the coordinator to ensure timely arrangements for transitions to higher or lower level of care and assist with transfer orders as needed.
• Ensure the concurrent or retrospective review process include referring cases that require clinical consultation with the medical director in a timely manner.
• Ensure cases are appropriately referred to Care Management, Behavioral health, Health Education, Housing, community health.
• Identify outliers and prepare documentation as well as report on potential quality of care issues as identified.
• Process timely completion of denials process per policy. The RN will review variances in cases followed by an LVN for possible consultation with the Medical Director to determine approval for due to medical necessity or denial of days.
• Conduct timely compliance and completion of documents per regulatory requirements.
• Serve as the company Liaison between hospitals, IPAs vendors, outside agencies and provider to ensure effective communication and collaboration to meet the Member's treatment plan and goals.
• Oversee verification of delivery of ordered Durable Medical Equipment (DME), Health Home visits, set up hospital follow up visits with PCP, review of Medications with Member and transportation needs.
• Oversee and complete Discharge planning assessment.
• Perform medication reconciliation based on acuity and type of medications.
• Outreach to Member post discharge to ensure Member attended follow up appointment, Health Home starts visits, possible in-home visit by RN or assigned LCSW as appropriate.
• Generate additional follow up needed to assign to appropriate regional Behavioral Health & Care Management team.
  
  

Requirements

Two (2) or more years of Utilization Management / Case Management in a health care delivery setting in Acute or Skilled nursing, with an emphasis on Concurrent Review and Utilization Management

Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required

Yes, must have a valid California Driver's license and valid automobile insurance

Must qualify and maintain driving record to drive company vehicles based on company insurance standards of no more than three (3) points

Knowledge of evidence based clinical criteria and California Children Services (CCS)

Must have analytical skills. Excellent communication, interpersonal and organizational skills

INDH

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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