Manager, In-Patient Review Nurses

Under the direction of the Clinical Director of Utilization Management (UM), is responsible for the oversight of the Inpatient Review Team. In this capacity, he/she will work with hospitals and IPAs to ensure coordinated and continuous cost-effective quality healthcare for IEHP Members.

1. Responsible for the oversight of concurrent and retrospective review for medical necessity, appropriateness of service and level of care.
2. Responsible for the day to day oversight of 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, Care Management, or other internal or external programs 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 daily review of the inpatient census report with subsequent follow up with the Inpatient Review Team for any outliers.
6. Work closely with the Inpatient Supervisors to review the daily inpatient productivity reports and subsequent follow-up with the Inpatient Review team members for any deficiencies.
7. Work closely with the Long-Term Care manager to ensure a smooth transition with transitions from one care setting to the next setting.
8. Collaborate with the Inpatient Review Nurse Supervisors on team member performance evaluations and coaching/counseling corrective action meetings with the assistance of Human Resource representative, up to and including termination. 
9. Responsible for monthly reports, such as Monthly Complex Cases, In-patient Days Denied, staff productivity, potential quality of care and any other reports needed for the inpatient team.
10. Analyze in-patient data, such as bed day reports, for trends and reviewing findings with UM Clinical Director and recommend opportunities for improvement.
11. Assist in the development of internal and external Policy and Procedure Manuals as necessary.
12. Responsible for staff education/training, completion of annual performance evaluations of inpatient staff timely, and counseling as needed.
13. Responsible for collaboration with Team Members, IPAs, hospitals, and any other external partners to support the goals of the department and the vision of the organization.
14. Lead and/ or participate in LEAN activities.

Five or more years’ experience in managed care with extensive knowledge of HMO and IPA operations with an emphasis on Concurrent Review and utilization management.

High school diploma or GED required.

Bachelor’s degree from an accredited institution preferred.

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

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

Analytical skills, time management, and problem solving.  Microcomputer applications (Microsoft Word and Excel, Access required) for use in all aspects of an office environment. Excellent communication, interpersonal and organizational skills.

Self-starter and a team player. 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.