Concurrent Review Nurse

This is a fully remote position, open to applicants in California.

📋 Description

• Perform onsite and/or telephonic concurrent reviews of inpatient activities.

• Ensure that member care is provided at the most suitable level and for the necessary duration, in accordance with HPSJ, regulatory, and contractual obligations.

• Validate member care plans in collaboration with providers.

• Identify care-related issues and work with providers to address them; escalate when needed.

• Provide timely recommendations regarding transfers, level-of-care assessments, and discharge planning.

• Refer non-standard requests to the Medical Director for evaluation.

• Approve or deny services as instructed.

• Investigate and resolve adjudication issues accurately and promptly.

• Record activities in the appropriate HPSJ systems in line with established standards.

• Monitor data as required.

• Aggregate data and generate routine reports for submission.

⛳️ Requirements

• Strong clinical competencies as outlined in California's scope of practice guidelines for RNs.

• Proficient in reading, interpreting, and applying complex written regulations, guidelines, and other documents.

• Ability to comprehend and interpret clinical information.

• Excellent assessment and analytical skills.

• Strong problem-solving abilities.

• Basic negotiation capabilities.

• Exceptional oral and written communication skills.

• Ability to professionally communicate with a diverse range of individuals and simplify complex information.

• Capacity to work autonomously and collaboratively within a team.

• Effective time management and organizational skills.

• Strong customer service orientation.

• Basic proficiency in Word and Excel.

• Competence in data entry and navigation through multiple databases.

• Ability to speak and be understood in English.

• May require proficiency in one of HPSJ’s threshold languages.

• Ability to manage confidential information with the utmost discretion.

• Comprehensive knowledge of concurrent review principles and practices to be acquired within six months of employment.

• In-depth understanding of government-sponsored programs and regulations as they pertain to concurrent review to be obtained within six months of hiring.

• Thorough knowledge of managed care principles, practices, and regulations related to concurrent review to be acquired within six months of employment.

• Extensive understanding of healthcare delivery systems in relation to concurrent review to be obtained within six months of hiring.

• Graduation from an accredited nursing program.

• A minimum of three years of clinical experience as an RN in a hospital or clinic setting.

• Valid and unrestricted California Registered Nurse license.

• Current California driver’s license and reliable transportation, or the ability to arrange transportation on demand in counties served by HPSJ if unable to obtain a driver’s license due to a medically documented disability.

• Legal and valid work authorization, Green Card, or U.S. citizenship.

• Preferred: experience in case management, utilization management, or discharge planning.

• Preferred: experience as a clinician within a managed care context.

• Preferred: experience working with Medi-Cal and/or Medicare populations.

🏝️ Benefits

• Comprehensive and affordable medical insurance options, including HMO and PPO plans.

• Employee Wellness Program that supports physical, mental, and financial health.

• Dental and vision plans with a variety of provider choices.

• Generous paid time off policy (accrue up to 3 weeks of PTO, 4 paid floating holidays, and 9 paid holidays).

• Participation in the CalPERS retirement pension program.

• Automatic employer-funded retirement contributions.

• Optional defined contribution plan.

• Two flexible spending accounts (FSAs) for healthcare and dependent care expenses.

• Employer-Paid Term Life and AD&D Insurance.

• Employer-Paid Disability Insurance.

• Employer-Paid Assistance Program (EAP).

• Health Advocacy services to assist you in navigating medical care and benefits.

• Optional supplemental benefits including medical, legal, and identity theft protection.

• Access to an online discount mall.

• Tuition reimbursement opportunities.

• Option for remote work based on business needs and company policies.

• Chance to work for a mission-driven organization.