Concurrent Review Nurse
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Job Description
Concurrent Review Nurse evaluating inpatient care and coordinating utilization decisions for HPSJ, a California health plan. Conducting clinical reviews, provider collaboration, and discharge planning.
Responsibilities:
- Conduct onsite and/or telephonic concurrent review of inpatient activities
- Ensure member care is rendered at the most appropriate level and for the requisite length of time in compliance with HPSJ, regulatory, and contractual requirements
- Confirm member care plans with providers
- Identify care issues and collaborate with providers to resolve them; escalate as necessary
- Make timely recommendations regarding transfers, level-of-care determinations, and discharge planning
- Escalate non-standard requests to the Medical Director for review
- Approve or deny services as directed
- Research and resolve adjudication issues accurately and timely
- Document activities in appropriate HPSJ systems according to standards
- Track data as required
- Compile data and produce and submit routine reports
Requirements:
- Strong clinical skills as defined in California scope of practice guidelines for RNs
- Ability to read, interpret, and apply complex written regulations, guidelines, and other materials
- Ability to read and interpret clinical information
- Strong assessment and analysis skills
- Strong problem-solving skills
- Basic negotiation skills
- Strong oral and written communication skills
- Ability to communicate professionally with diverse individuals and explain complex information
- Ability to work independently and as part of a team
- Time management and organizational skills
- Strong customer service skills
- Basic skills in Word and Excel
- Ability to enter data into and navigate through multiple databases
- Ability to speak and be understood in English
- May require proficiency in one of HPSJ’s threshold languages
- Ability to handle confidential information with appropriate discretion
- In-depth knowledge of the principles and practices of concurrent review required within six months of hire
- In-depth knowledge of government-sponsored programs and regulations as they apply to concurrent review required within six months of hire
- In-depth knowledge of managed care principles, practices, and regulations as they apply to concurrent review required within six months of hire
- In-depth knowledge of healthcare delivery systems as they apply to concurrent review required within six months of hire
- Graduation from an accredited nursing school
- At least three years of clinical experience as an RN in a hospital or clinic
- Unrestricted California Registered Nurse license
- Valid California driver license and reliable transportation, or ability to obtain transportation on demand in counties served by HPSJ if prohibited from getting a driver license due to a medically documented disability
- Legal and valid work authorization, Green Card, or U.S. citizenship
- Preferred: experience in case management, utilization management, or discharge planning
- Preferred: experience as a clinician in a managed care setting
- Preferred: experience working with Medi-Cal and/or Medicare populations
Benefits:
- Robust and affordable medical coverage including HMO and PPO plan options
- Employee Wellness Program promoting physical, mental, and financial well-being
- Dental and vision plan with multiple provider choices
- Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays, and 9 paid holidays)
- CalPERS retirement pension program
- Automatic employer-paid retirement contributions
- Voluntary defined contribution plan
- Two flexible spending accounts (FSAs) for healthcare and dependent care expenses
- Employer-Paid Term Life and AD&D Insurance
- Employer-Paid Disability Insurance
- Employer-Paid Assistance Program (EAP)
- Health Advocacy to help you navigate medical care and benefits
- Voluntary supplemental benefits including medical, legal, identity theft protection
- Online discount mall
- Tuition reimbursement
- Remote work contingent on business needs and company guidelines
- Opportunity to work for a mission-driven organization
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