Inpatient Review Nurse, California RN/LVN License Required

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

📋 Description

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

• Initiate 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 in outpatient care or lower-level care environments.

• Timely review inpatient admissions to determine the appropriate level of care and length of 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 members in need of complex or chronic case management post-discharge and facilitate warm handoffs.

• Partner with IPA/MG for effective management of members.

• Supervise and assign daily activities and responsibilities to the CCIP Coordinator.

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

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

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

• Keep track of overutilization or underutilization cases.

• Make appropriate referrals to the Quality Management department as needed.

• 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 other assigned tasks.

⛳️ Requirements

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

• At least 2 years of experience applying Milliman Care Guidelines to substantiate inpatient versus observation length of stay, including diagnosis review and length of stay assessment.

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

• Completion of an accredited Licensed Vocational Nursing Program.

• Active, valid, and unrestricted LVN or RN license in California (Non-Compact).

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

• Strong communication skills, demonstrating positivity, professionalism, and effectiveness; ability to lead, teach, and collaborate.

• Excellent critical thinking abilities related to nursing utilization review.

• Familiarity with Medicare Managed Care Plans.

• Proficient written and verbal communication skills, capable of maintaining positive relationships with diverse members, management, employees, and vendors.

• Capability to perform mathematical calculations and compute simple statistics.

• Ability to prioritize multiple tasks and employ advanced problem-solving and reasoning skills.

• Strong organizational, problem-solving, and time management abilities.

• Capacity to thrive in a fast-paced environment.

• Competence in understanding and analyzing statistical reports.

🏝️ Benefits

• Reimbursement for LVN and/or RN licensure in Nevada, Arizona, North Carolina, and Texas.