Long Term Care Review Nurse, RN (Hybrid Work Schedule)

Position Summary/Position

Under the direction of the Long Term Care (LTC) Review Nurse Manager and Supervisor, the incumbent will 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), Care Management, and/ or community-based services 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. (e.g., NOMNC)
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. Responsible for coaching the inpatient review nurse as the subject matter expert regarding the clinical review of skilled and custodial Members.
8. Responsible for rounds with the Medical Director in clinical rounds on complex long term care cases.
9. Support internal and external partners; attend meetings as the SME for LTC Clinical.
10. Assist the LTC Management team in creating and analyzing utilization reports.
11. Assist with clinical review of admission requests for skilled and custodial placement from the community.

Major Functions (Duties and Responsibilities) Cont

Supervisory Responsibilities

Experience Qualifications

Two (2) or more years of utilization management/case management in a health care delivery setting preferably in skilled nursing, with an emphasis on Concurrent Review and utilization management.

Preferred Experience

Education Qualifications

High school diploma or GED required.

Preferred Education

Professional Certification

Professional Licenses

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

Drivers License Required

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.

Working Conditions

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.

Position is eligible for telecommuting/remote work location model upon completing the necessary steps and receiving HR approval. The incumbent approved to telecommute may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs determined by IEHP leadership.

Work Model Location

Physical Requirements