LVN or RN as a Concurrent Review Nurse
Under the general direction of the Director UM, the Concurrent Review Nurse performs concurrent review functions for members admitted to a facility, manages the utilization throughout the admission and transition of care, conducts chart review for medical appropriateness of services, and ensures that quality care is delivered in a cost-effective manner. The Concurrent Review Nurse works in coordination with an interdisciplinary team to achieve the organization mission as well as department specific goals and objectives.
Current unrestricted Licensed Vocational Nurse (LVN) or Registered Nurse (RN) license for the State of California- required.
Knowledge of HMO/IPA requirements and benefits that apply to the utilization management process- preferred.
Three (3) years of prior clinical experience: hospital clinical/direct patient care experience or the equivalent, strongly- preferred.
Three (2) years of prior managed care experience: acute hospital case management, discharge planning, complex case management or utilization management- preferred.
ESSENTIAL DUTIES AND REPONSIBILITIES
Performs concurrent, prior authorization and retrospective reviews according to established policies, procedures, and review guidelines.
Ensures authorizations are processed according to established timelines, benefit coverage, and medical necessity criteria within the appropriate provider network.
Performs reviews telephonically and offsite at assigned facilities. Maintains communication with office, mobile workstation and accounts for hours worked and breaks while performing offsite reviews.
Monitors that all services are being delivered in the most the appropriate setting and level of care and appropriate health care providers on the case.
Provides disposition planning assessment of prior levels and current needs to facilitate the coordination of services and utilization of resources to ensure a safe and appropriate transition into the most appropriate setting and facilitates discussion of alternative treatment plans with the interdisciplinary team.
Identifies services required by health plan members that cannot be provided within the IPAs network of providers and locates alternative providers and facilities as required.
Acts as a liaison and resource in collaboration with physicians and their office staff, hospitalists, care facilities, ancillary providers, members, health plan case managers and internal departments.
Ensures denial and termination of services are delivered timely and member and providers are notified of appeal rights.
Process authorizations and secure outpatient follow-up appointments and scheduling tests, outpatient procedures and services with appropriate health care providers.
Interprets data and trends using appropriate analytical skills to include utilizing existing reports and systems to identify and monitor utilization patterns.
Provides timely responses to inquiries from health plans and providers concerning members who are admitted to a facility.
Makes appropriate referrals and coordinates as needed with the health plan for delegated and non-delegated concurrent review and coordination activities.
Identifies members who are appropriate for Case Management services and will need oversight of outpatient care and compliance to avoid unnecessary readmissions.
Works closely with UM department, Quality Management, Provider Relations, Contracting and Claims staff to prevent duplication of services, ensure appropriate care is rendered with contracted providers, identify high risk patients, and support quality improvement initiatives.
Assists in data collection for special studies, and medical chart reviews to meet the organizations goals and objectives.
Participates in department program planning including goal setting, program development, systems development and improvement.
EXCEL provides comprehensive health care management services with a personalized approach to meet each clients needs. EXCEL combines advanced technological solutions with a sophisticated level of healthcare expertise to provide effective management and solutions to a rapidly changing health care environment. EXCEL has been operating as an independent health care management company since 2001, although originally rooted during 1980 as an institutional management arm.