Concurrent Review Nurse
Under general supervision, conducts onsite and/or telephonic concurrent review of inpatient activities. In addition, this position is responsible for ensuring that member care is rendered at the most appropriate level, for the requisite length of time, in compliance with HPSJ, regulatory and contractual requirements. Work is varied and complex and requires a moderate amount of discretion and independent judgement.
What you'll do:
- Confirms member care plan with provider.
- Identifies care issues and collaborates with provider to resolve; escalates as necessary.
- Makes timely and appropriate recommendations regarding transfers, determination of level of care and discharge planning.
- Escalates non-standard requests to Medical Director for review; approves or denies services as directed.
- Researches and resolves adjudication issues in an accurate and timely manner.
- Documents activities in appropriate HPSJ system(s) according to standards.
- Tracks data as required; compiles data for, produces and submits routine reports.
- Strong clinical skills as defined in California scope of practice guidelines for RN’s.
- Ability to read, interpret and apply complex written regulations, guidelines and other materials; ability to read and interpret clinical information.
- Produces work that is accurate and complete.
- Produces the appropriate amount of work.
- Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
- Rebounds from setbacks and adversity when facing difficult situations.
- Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
- Strong skills in assessment and analysis.
- Strong problem solving skills.
- Basic negotiation skills.
- Interpersonal skills - interacts effectively with individuals both inside and outside of HPSJ; relates openly and comfortably with diverse groups of people.
- Strong oral and written communication skills, with the ability to communicate professionally to diverse individuals inside and outside of HPSJ, effectively explain complex information, and document according to standards.
- Ability to use tact and diplomacy to diffuse emotional situations.
- Ability to work independently and as part of a team.
- Time management and organizational skills. Uses time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines.
- 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 (as defined by HPSJ’s Cultural and Linguistic Program).
- Ability to handle confidential information with appropriate discretion.
Required within six months of hire
- In-depth knowledge of the principles and practices of concurrent review.
- In-depth knowledge of government sponsored programs and regulations as they apply to concurrent review.
- In-depth knowledge of managed care principles, practices and regulations as they apply to concurrent review.
- In-depth knowledge of health care delivery systems as they apply to concurrent review.
- Graduation from an accredited nursing school.
- At least three years clinical experience as an RN in a hospital or clinic.
- Experience in case management, utilization management or discharge planning.
- Experience as a clinician in a managed care setting.
- Experience working with Medi-Cal and/or MediCare populations.
Licensure, Certification, Registration
- Unrestricted California Registered Nurse license.
- Valid California driver license and reliable transportation or, the ability to obtain transportation on demand in the counties served by HPSJ if prohibited from getting a driver license due to a medically documented disability.