Concurrent Review Nurse, RN

Under the direction of the Inpatient Review Nurse Manager and Supervisor, the incumbent will work with hospitals and IPAs, in collaboration with their assigned Team Center, that may include an Discharge Planner and Inpatient Coordinator, to initiate coordinated and continuous cost effective quality healthcare to ensure the continuity of the Member’s care needs are met timely and readmission prevention is anticipated for IEHP Members.

1. Responsible for the oversight of concurrent and retrospective reviews for medical necessity per evidenced based criteria, appropriateness of service and level of care, either through telephonic review, clinical documentation submitted by respective facilities and/or electronic medical records (EMR) access.
2. Responsible for conducting reviews to ensure that Member’s treatment plan is consistent with diagnosis(es), specifically initial review within 24 hours to ensure Member’s meet specified criteria for the respective admission.
3. Responsible for working in collaboration with the Discharge Planner and Inpatient Coordinator to ensure timely arrangements for transitions to higher or lower level of care and assist with transfer orders as needed.
4. Responsible for oversight of authorizations for outpatient services or ancillary services as ordered, in preparation for the Member’s discharge in collaboration with Discharge Planner
5. Responsible for providing oversight and ensuring that the concurrent or retrospective review process includes referring Members to Health Management, Health Education, Care Management, Behavioral Health or other internal or external programs as needed in collaboration with Discharge Planner.
6. Responsible for ensuring that the concurrent or retrospective review process includes referring cases that require clinical consultation with the Medical Director in a timely manner and per assigned rounds schedule.
7. Responsible for identifying outliers and preparing documentation as well as reports on potential quality of care issues as identified.
8. Responsible for timely completion of denials process per policy.
9. Responsible for timely compliance and completion of documents as required by regulatory requirements.
10. Serve as the IEHP liaison between hospitals, IPAs, vendors, outside agencies, and providers to ensure effective communication and collaboration in an effort to meet the Members treatment plan and goals.
11. Responsible for working with other Team Members, departments,  IPAs and the facilities to support the goals of the department as well as strategic priorities and vision of the organization.

Two or more years of utilization management/case management in a health care delivery setting, with an emphasis on Concurrent Review and utilization management.

High school diploma or GED required.

Possession of an Active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN

Knowledge of evidence based clinically criteria and California Children Services (CCS).

Must have analytical skills. Excellent communication, interpersonal and organizational skills.

Self-starter and a team player. Time management and problem solving abilities. Must have a high degree of patience.

The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.