- Perform reviews of inpatients with complex medical and social problems.
- Generate referrals to contracted ancillary service providers and community agencies with the agreement of the patient's primary care physician.
- Perform follow-up reviews and evaluations of patients in the ambulatory care or lower level of care setting.
- Review inpatient admissions timely and identifies appropriate level of care and continued stay based on acceptable evidence based guidelines used by CCHP.
- Effectively communicate with patients, their families and or support systems, and collaborates with physicians and ancillary service providers to coordinate care activities.
- Identify members who may need complex or chronic case management post discharge and warm handoff to appropriate staff for ambulatory follow up as necessary.
- Communicates and collaborates with IPA / MG as necessary for effective management of Members.
- Assigns and provides daily oversight of the activities and tasks of the CCIP Coordinator.
- Records communications in EZ-Cap and / or case management database.
- Arranges and participates in multi-disciplinary patient care conferences or rounds.
- Monitor, document, and report pertinent clinical criteria as established per UM policy and procedure.
- Monitor for any over utilization or under utilization activities.
- Generate referrals as appropriate to the QM department.
- Enters data as necessary for the generation of reports related to case management.
- Report the progress of all open cases to the medical director, director of healthcare services, and manager of utilization management.
- Successful completion of an accredited Licensed Vocational Nursing Program
- Current, active, and unrestricted California Licensed Vocational Nurse.
- Experience with concurrent review required.
- Experience utilizing Milliman Care Guidelines (MCG) required.
- Minimum of (2) consecutive years related experience in a managed care setting as an inpatient case manager
- Minimum (3) years of general case management experience
- Knowledge of Medicare Managed Care Plans
- Possess excellent critical thinking skills related to nursing
- Experience in complex / catastrophic case management preferred
- Must be proficient in Microsoft Word, Excel, and Outlook
- Strong written and verbal communication skills
- Strong interpersonal skills to establish and maintain a constructive relationship with diverse members, management, employees and vendors.
- Able to perform mathematical calculations and calculate simple statics correctly
- Able to prioritize multiple tasks; advanced problem-solving
- Able to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
- Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment
- Able to comprehend and analyze basic reports
- While performing the duties of this job, the employee is regularly required to sit; use hands to finger, hand, or feel and talk or hear.
- The employee is frequently required to reach with hands and arms
- The employee is occasionally required to climb or balance and stoop, or kneel
- The employee must occasionally lift and / or move up to 20 pounds.
- Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.
-
Inpatient Review RN
1 week ago
Alignment Healthcare , CA, United StatesOverview of the Role: · Alignment Health is seeking a remote inpatient review nurse (must have California license) to join the utilization management (UM) team. As an inpatient review nurse, you get to assist patients through the continuum of care in collaboration with the patien ...
-
Inpatient Review RN
1 week ago
Alignment Health California, United StatesJob Number: 6669 · Workplace Type: Fully Remote · Position Title: Inpatient Review Nurse · External Description · Overview of the Role: · Alignment Health is seeking a remote inpatient review nurse (must have California license) to join the utilization management (UM) team. As an ...
-
remote inpatient review rn
2 weeks ago
Alignment Healthcare California, USA, United StatesOverview of the Role: · Alignment Health is seeking a remote inpatient review nurse for a long-term temporary engagement (with medical benefits) to join the utilization management (UM) team. As an inpatient review nurse, you get to assist patients through the continuum of care in ...
-
Remote Inpatient Review RN
3 weeks ago
Alignment Health California, United StatesJob Number: 6651 · Workplace Type: Fully Remote · Position Title: Inpatient Review Nurse · External Description · Overview of the Role: · Alignment Health is seeking a remote inpatient review nurse for a long-term temporary engagement (with medical benefits) to join the utilizati ...
-
Claims Auditor
1 day ago
Russell Tobin California, United StatesTitle: Claims Compliance Auditor · Start: ASAP · W2 Contract Duration: 6 months · Location: Remote · Hours per Week: Flexible for Part-Time or Full-Time; 20-40 hours/week · Pay Range: $75-95/hr · Skills required: · Significant healthcare claims experience and health claims reven ...
-
Care Specialist
2 days ago
netPolarity, Inc. (Saicon Consultants, Inc.) California, United StatesMonitors inpatient and/or outpatient level of care services related to mental health and substance abuse treatment to ensure medical necessity and effectiveness. Provides telephone triage, crisis intervention and emergency authorizations as assigned. Performs concurrent reviews f ...
-
utilization review
2 weeks ago
Acadia Healthcare Inc. , CA, United StatesSan Jose Behavioral Health currently has an opportunity for a Utilization Review Specialist Per Diem, at our new 133 bed Acute Psychiatric Hospital, located in South San Jose, CA. · At San Jose Behavioral Health, our counseling professionals provide treatment and support to assis ...
-
Call Center Representative
3 weeks ago
Insight Global California, United StatesMust Haves: · • 2+ years of RECENT high volume (80+) call center experience, ideally includes some outbound call center experience (in a REMOTE setting) · • No more than 3mo work gap since last role · • Have been in past positions for 1+ years (do not want candidates who have b ...
-
case manager utilization rn, 40/hr night
1 week ago
Kaiser Permanente , CA, United StatesSign On Bonus for Eligible External Hires · Job Summary: · Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the ...
-
UM BH Nurse, RN
1 week ago
Inland Empire Health Plan , CA, United StatesWhat you can expect · Find joy in serving others with IEHP We welcome you to join us in "healing and inspiring the human spirit" and to pivot from a "job" opportunity to an authentic experience · Under the direction of the Supervisor, UM Inpatient & Specialty - CCA, the incumbent ...
-
clinical review nurse
2 weeks ago
Centene Corporation , CA, United StatesYou could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. ...
-
Pediatric Hospitalist Physician
1 week ago
Inspire Healthcare California, United States: · 24/7 coverage on Acute Care units by pediatric hospitalists. · Hospitalists are the pediatrician of record during a patients stay. They coordinate with the primary care physician and all subspecialists that need to see the individual patient. · Provide rapid assessment to ...
-
Radiologist Full Time
1 week ago
Physician Empire California, United States Full timeCentral Valley · 30 miles to Stockton · 60 miles to Sacramento · 90 miles to downtown San Francisco · 100 mile to Yosemite National Park · 3 hours to Lake Tahoe · FM & Orthopedic Residency programs · Well-established Physician-owned Northern California private practice is ...
-
registered nurse ii/iii/iv qi inpatient program
2 weeks ago
County of Riverside, CA , CA, United StatesABOUT THE POSITION · The County of Riverside - Riverside University Health System - Behavioral Health is currently recruiting for Registered Nurse II/III/IV for the QI - Inpatient Program located in Riverside. Incumbents in this position will be responsible for the following: · * ...
-
advance practice nurse/clinical nurse specialist
2 weeks ago
Scripps Health , CA, United StatesScripps Health Administrative Services supports our five hospitals and 19 outpatient facilities, which treat half a million patients annually through 2,600 affiliated physicians. · Join the Scripps Health team and work alongside passionate caregivers and provide patient-centered ...
-
Remote Utilization Management
1 week ago
Alignment Healthcare , CA, United StatesOverview of the Role: · Alignment Health is seeking a collaborative and tech savvy LVN / LPN utilization management (UM) nurse (must have California license), for a long-term temporary engagement (with medical benefits) to join the remote, utilization management, pre-service team ...
-
remote inpatient utilization management
2 weeks ago
Alignment Healthcare California, USA, United StatesOverview of the Role: · Alignment Health is seeking an organized, detail-oriented and customer service oriented inpatient utilization management (UM) coordinator to join the UM team. As an inpatient UM coordinator, you will assist with managing census and admissions, retrieve med ...
-
Registered Nurse
4 days ago
Amerit Consulting California, United StatesPosition: Utilization Management Nurse · Location: REMOTE in CA · Duration: 6+ Months Contract with possible extension · Pay Rate: $55/hr - $64/hr (depending on experience) · Relocation Expenses/ Assistance: NO · Schedule: M-F: 8:00 – 5:00p pacific · Job Description: · The Medic ...
-
inpatient pharmacy specialist
3 weeks ago
Kaiser Permanente , CA, United States Part timeJob Summary: · Under indirect, or direct supervision and based on the understanding of patient variables such as age, sex, and other physical characteristics: monitors or manages the medication therapy of hospitalized or ambulatory patients as assigned; confers with and assists m ...
-
Behavioral Health Technician
1 week ago
D'Amore Mental Health California, United StatesHere at D'Amore Healthcare we treat patients with primary mental health needs in an inpatient setting centrally located in Costa Mesa, Orange County. We are looking for an exceptionally organized, compassionate, team player with precision documentation, time management, and group ...
Remote Inpatient Review RN - , CA, United States - Alignment Healthcare
Description
Overview of the Role:
Alignment Health is seeking a remote inpatient review nurse (must have California license) for a long-term temporary engagement (with medical benefits) to join the utilization management (UM) team.
As an inpatient review nurse, you get to assist patients through the continuum of care in collaboration with the patient's primary care physician, facility case manager, discharge planner and employing contracted ancillary service providers and community resources as needed.
You will also ensure that services are provided at the most appropriate, cost effective level of care needed to meet the patient's medical needs while maintaining safety and quality.
Note:
Since Alignment Health is continuing to expand, there is a possibility the engagement could possibly extend and / or convert depending on budget, business need, and individual performance.
Responsibilities:
Required Skills and Experience:
Pay Rate:
$73, $98,000.00 annually.
&v=024){kind=logo}
