Long Term Care Review Nurse, LVN - 4/10 Weekend Shift (Remote)

Date: Nov 17, 2021

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 5871 


Position Summary/Position


Under the direction of the Long Term Care (LTC) Review Nurse Manager and Supervisor, the incumbent will, in conjunction with the LTC RN Lead Nurse, work with hospitals, skilled nursing facilities and IPAs to ensure coordinated and continuous cost effective quality healthcare for IEHP Members.

Major Functions (Duties and Responsibilities)


1. Responsible for concurrent and retrospective reviews for medical necessity, appropriateness of service and level of care for skilled and long term care.
2. Responsible for authorizations for outpatient services or ancillary services in preparation for the Member’s discharge or transition to lower level or higher level of care.
3. Responsible for ensuring that the concurrent or retrospective review process includes referring Members to Health Management, Health Education, Transitions of Care (TOC) and/or Care Management as needed.
4. Responsible for ensuring that the concurrent or retrospective review process includes referring cases that require physician review to the Medical Director in a timely manner.
5. Responsible for timely compliance and completion of documents as required by CMS & NCQA.
6. Responsible for working with other Team Members, departments,  IPAs and the hospitals to support the goals of the department and the vision of the organization.
7. Work with the LTC RN Lead Nurse to identify complex cases in preparation for rounding with the Medical Director.

Experience Qualifications


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

Preferred Experience


Two or more years of utilization management/case management in a health care delivery setting preferably in skilled nursing.

Education Qualifications


High school diploma or GED required.

Professional Licenses


Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California BRN.

Drivers License Required

Yes, must have a valid California Driver's License.

Knowledge Requirement


Responsible for the performance of concurrent and retrospective reviews for medical necessity and appropriateness of service and care. Knowledge of evidence based clinically criteria and California Children Services (CCS).

Skills Requirement


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

Abilities Requirement


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

Commitment to Team Culture


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.


Starting Salary: $57,948.80  - $73,860.80  

Pay rate will commensurate with experience


Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles