Location: Fully remote- PST
Shift: Monday through Friday 8am to 5pm (PST)
Duration: 5+ months,
potential to extend, this is a temp backfill for CA employee(s) on FMLA- need RN resumes.
Job Description: Position Purpose:
Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.
Education/Experience
Requires Graduate from an Accredited School of Nursing or Bachelors degree in Nursing and 2 4 years of related experience.
Walk me through the day to day responsibilities of this the role and a description of the project:
- Summary: Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to emergent/urgent and continued stay reviews.
- Job Responsibilities: Perform review of concurrent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director for secondary review. Complete medical necessity and level of care reviews for requested services using InterQual guidelines and refer to Medical Directors for review depending on case findings. Collaborate with various staff within provider networks and discharge planning team electronically and telephonically to coordinate member care. Conduct discharge planning. Educate providers on utilization and medical management processes. Provide clinical knowledge and act as a clinical resource to non-clinical team staff. Enter and maintain pertinent clinical information in various medical management systems.
Describe the performance expectations/metrics for this individual and their team:
- Nurses are expected to Review an average of 20 cases/day
License/Certification
LPN - Licensed Practical Nurse - State Licensure required.
Job Duties
Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care
Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member
Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered
Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines
Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings
Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members
Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines
Reviews members transfer or discharge plans to ensure a timely discharge between levels of care and facilities
Collaborates with care management on referral of members as appropriate
Performs other duties as assigned
Pay Rate: $40 - 44/hr