UM Onsite Inpatient Nurse Reviewer (Hybrid Work Schedule)

Position Summary/Position

Under the direction of the Supervisor, UM Clinical RN - Inpatient, the incumbent will work autonomously with hospitals and IPAs to perform concurrent and discharge nurse functions, to ensure medically necessary post stabilization care and coordinate emergent admissions and diversions. The core functions would include but are not limited to transition and/or diversion of stabilized members from an Emergency Department to a contracted, in network facility, home disposition with coordinated care for Home Health/Durable Medical Equipment, and/or other wrap around services that would ensure a continuity of Member’s care needs, cost effective discharge planning and prevention of readmissions.

Major Functions (Duties and Responsibilities)

1. Aligns with the mission, vision, and values of the organization. Participates actively in obtaining goals set for the department.
2. Demonstrates an awareness of personal learning need x and seeks ways to meet these needs to promote both clinical and management development.
3. Demonstrates accountability for own clinical practice.
4. Attends rounds (face to face) with the CM and/or hospitalists at the facility/hospital assigned as scheduled.
5. Reviews hospital and member’s request for inpatient admission. Utilizes nationally recognized criteria to ensure request is justified and medically necessary.
6. Effectively communicates with facility and hospitalists, and IEHP internal Team Members, to provide assessment and clinical data transfer.
7. Interacts and serves as the liaison between IEHP, hospitalists, SNFists, IPAs, Members and their caregivers and/or family daily, to evaluate and communicate the plan of care including discharge planning to determine that Members are receiving quality care and appropriate discharge disposition to the safest, most appropriate level of care.
8. Applies critical thinking, evidenced based criteria, nursing and medical knowledge to authorize services as an alternative to admission when appropriate.
9. Arranges and coordinates repatriation/transfer of Members from out of area or out of network to in-network care facilities when appropriate including facilitation of bed assignments, transportation, physician to physician communication, and other repatriation responsibilities as need to ensure a smooth transition of Member’s to alternate care settings.
10. Identifies comprehensive subjective and objective Member information for the purpose of concurrent and retrospective review of an inpatient admission for medical necessity per evidenced based criteria, appropriateness of service and level of care
11. Coordinates authorizations for emergency admission once it is determined that a Member is not stable for transfer to an alternate facility or determined to be unstable for transfer.
12. Coordinates authorization for wrap around services including but not limited to ancillary services requests (i.e., home health, durable medical equipment), transportation, health education, care management and/or other specialty services.
13. Continues efforts for difficult and/or urgent placements to appropriate care setting as assigned for higher and lower levels of care
14. Assists with conducting reviews as assigned to ensure that Member’s treatment plan is consistent with admitting diagnosis. If Member does not meet admission criteria, initiate diversion process and clearly document why criteria was not met.
15. Communicate with hospitals, skilled nursing facilities, and IPAs to educate of the need for meeting criteria for admission.

Experience Qualifications

Three (3) years of clinical experience in a health care delivery setting. Acute Care Experience required.

Preferred Experience

ED or ICU experience preferred.

Education Qualifications

High school diploma or GED required OR Vocational OR technical training in Nursing.

Preferred Education

Associate's degree in Registered Nursing from an accredited institution preferred.

Professional Licenses

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

Drivers License Required

Skills Requirement

Critical thinker. Effective communicator. Extremely organized.

Abilities Requirement

Demonstrates self-direction and the ability to work autonomously in establishing priorities and working with little supervision. Maintains high level of precision in clinical judgment, accuracy of assessment, and skill in problem solving under stress. Relates and communicates well over the telephone to all callers including peers, leadership as well as external and internal partners.

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.