Inpatient Review Nurse – California RN/LVN License Required

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

📋 Description

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

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

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

• Timely review inpatient admissions to determine the suitable level of care and length of stay based on established evidence-based guidelines.

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

• Identify members who require complex or chronic case management post-discharge and facilitate seamless transitions for outpatient follow-up.

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

• Delegate and oversee daily activities and tasks of the CCIP Coordinator.

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

• Organize and actively participate in multidisciplinary patient care conferences or rounds.

• Monitor, document, and report relevant clinical criteria according to UM policies and procedures.

• Oversee 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.

• Execute other assigned responsibilities.

⛳️ 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 Length of stay, including assessment of diagnosis and duration of stay.

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

• Successful completion of a licensed vocational nursing program accredited by the appropriate authorities.

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

• Strong communication skills with the ability to engage positively, professionally, and effectively with others; provide leadership, training, and collaboration.

• Excellent critical thinking abilities related to nursing utilization review.

• Familiarity with Medicare Managed Care Plans.

• Proficient written and oral communication skills; capability to foster and maintain constructive relationships with diverse members, management, staff, and vendors.

• Competence in performing mathematical calculations and accurately calculating simple statistics.

• Ability to prioritize multiple tasks; advanced problem-solving capabilities; adept at using advanced reasoning to identify 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.

• Proficient in understanding and analyzing statistical reports.

🏝️ Benefits

• Equal Opportunity/Affirmative Action employment consideration.

• Reasonable accommodations for individuals with disabilities.