Inpatient Review Nurse, California RN/LVN License Required

This is a fully remote position, open to applicants in Arizona, +4 more states.

📋 Description

• Support patients throughout the continuum of care by collaborating with primary care physicians, facility case managers, discharge planners, contracted ancillary service providers, and community resources.

• Ensure that services are delivered at the most suitable and cost-effective level of care while upholding safety and quality standards.

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

• Create referrals to contracted ancillary service providers and community agencies.

• Carry out follow-up reviews and assessments in ambulatory or lower-level care environments.

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

• Facilitate communication with patients, families, physicians, and ancillary service providers to ensure coordinated care.

• Identify members requiring complex or chronic case management post-discharge and provide seamless transitions.

• Collaborate with IPA/MG for effective member management strategies.

• Assign and supervise activities and tasks of the CCIP Coordinator.

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

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

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

• Oversee overutilization and underutilization activities.

• Generate referrals to the QM department.

• 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

• A minimum of 3 years' experience in general case management.

• At least 2 years' experience using Milliman Care Guidelines for inpatient versus observation length-of-stay reviews.

• A minimum of 2 consecutive years of relevant experience in a managed care environment as an inpatient case manager.

• Successful completion of an accredited Licensed Vocational Nursing Program is required.

• An active, valid, and unrestricted RN license in California (Non-Compact) is mandatory.

• Must be prepared to obtain LVN and/or RN licensure in Nevada, Arizona, North Carolina, and Texas immediately upon hire.

• Strong ability to communicate positively, professionally, and effectively; provide leadership, teach, and collaborate.

• Excellent critical-thinking skills related to nursing utilization review.

• Familiarity with Medicare Managed Care Plans.

• Proficient written and verbal communication abilities.

• Capability to maintain constructive relationships with a diverse range of members, management, employees, and vendors.

• Aptitude for performing mathematical calculations and basic statistical analysis.

• Ability to prioritize various tasks and apply advanced problem-solving and reasoning skills.

• Strong organizational and time-management skills; capacity to thrive in a fast-paced environment.

• Competence in understanding and analyzing statistical reports.

• Preferred: experience working with a senior population.

• Preferred: knowledge and experience in complex/catastrophic case management.

• Must be available to work Monday through Friday, from 8:00 AM to 5:00 PM Pacific Time.

• Ability to meet specified physical requirements, including occasional lifting or moving up to 20 pounds.

🏝️ Benefits

• Company reimbursement for licensure in Nevada, Arizona, North Carolina, and Texas.

• Equal Opportunity/Affirmative Action Employer.