Inpatient Review Nurse, CA LVN/RN License

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

📋 Description

• Assist patients throughout their care journey in partnership with primary care physicians, facility case managers, discharge planners, contracted ancillary service providers, and community resources.

• Conduct assessments of inpatients facing complex medical and social challenges.

• Facilitate referrals to contracted ancillary service providers and community agencies with the patient’s primary care physician's consent.

• Carry out follow-up reviews and evaluations for patients in ambulatory care or lower levels of care.

• Timely review inpatient admissions to determine the appropriate level of care and continued stay based on evidence-based guidelines.

• Engage with patients, families, and support systems, collaborating with physicians and ancillary service providers to ensure coordinated care.

• Identify patients requiring complex or chronic case management post-discharge and facilitate warm handoffs to the appropriate staff.

• Communicate and collaborate with IPA/MG for effective member management.

• Assign and oversee the daily activities and tasks of CCIP Coordinators.

• Document communications in EZ-Cap and/or the case management database.

• Organize and engage in multidisciplinary patient care conferences or rounds.

• Monitor, document, and report relevant clinical criteria in accordance with UM policy and procedures.

• Supervise overutilization and underutilization activities.

• Generate referrals to the QM department as necessary.

• Input data for case management reports.

• Update the Medical Director, Director of Healthcare Services, and Manager of Utilization Management on the progress of open cases.

• Perform additional duties as assigned.

⛳️ Requirements

• At least 3 years of general case management experience.

• Minimum of 2 years of experience using Milliman Care Guidelines to determine Inpatient versus Observation lengths of stay, including review of diagnoses and stay durations.

• Two consecutive years of relevant experience in a managed care environment as an inpatient case manager.

• Successful completion of an accredited Licensed Vocational Nursing Program.

• Strong ability to communicate positively, professionally, and effectively with others; capable of providing leadership, teaching, and collaboration.

• Excellent critical thinking skills related to nursing utilization review.

• Familiarity with Medicare Managed Care Plans.

• Proficient written and oral communication skills; ability to build and maintain constructive relationships with diverse members, management, employees, and vendors.

• Capability to perform mathematical calculations and accurately compute simple statistics.

• Ability to prioritize multiple tasks; advanced problem-solving skills; adept at using advanced reasoning to define problems, gather data, establish facts, draw valid conclusions, and design, implement, and manage effective resolutions.

• Strong problem-solving, organizational, and time management skills with the ability to thrive in a fast-paced environment.

• Skillful in understanding and analyzing statistical reports.

• Current, active, and unrestricted California Licensed Vocational Nurse.

🏝️ Benefits

• Ample opportunities for growth and innovation.

• Equal Opportunity/Affirmative Action employment.