Clinical - Clinical Review Nurse - Concurrent Review

New Yesterday

General Information Job Description: Job Profile Summary Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.
Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience. 2+ years of acute care experience required.
Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred.
License/Certification: LPN - Licensed Practical Nurse - State Licensure required For Health Net of California: RN license required
Responsibilities Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care
Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member
Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered
Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines
Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings
ssists with providing education to providers on utilization processes to ensure high quality appropriate care to members
Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines
Reviews member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities
Collaborates with care management on referral of members as appropriate Performs other duties as assigned
Complies with all policies and standards Comments for Vendors: RN TX license
Centene Job Description Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.
Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience. 2+ years of acute care experience required.
Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred.
License/Certification: LPN - Licensed Practical Nurse - State Licensure required- TX cannot take LPN's. they have to be at least a RN For Health Net of California: RN license required
Responsibilities Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care
Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member
Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered
Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines
Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings
ssists with providing education to providers on utilization processes to ensure high quality appropriate care to members
Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines
Reviews member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities
Collaborates with care management on referral of members as appropriate Performs other duties as assigned
Complies with all policies and standards Story Behind the Need - Business Group & Key Projects Health plan or business unit Team culture Surrounding team & key projects Purpose of this team Reason for the request Motivators for this need ny additional upcoming hiring needs? TX has doubled in enrollment this year so far. We are needing nurses who can cover late shift 10am-7 pm and weekends as that is our highest need right now. This will be for Texas Ambetter Superior Health Product. Our team is a team player centered culture and we try to have fun within our weekly huddles to keep morale up through the high caseload. Typical Day in the Role Daily schedule & OT expectations Typical task breakdown and rhythm Interaction level with team Work environment description • The nurse will be reviewing about 20 cases a day to review for medical necessity on a member that admits to the hospital. Job is to advocate and protect the member from unnecessary admissions to the hospitals. Nurse has to follow many changes and processes to complete the authorizations. Will be working with a group of nurses to assist each other and collaborate on getting the cases done. The nurse will be in contact with doctors and case managers to achieve decisions and/or receive more information about the member's condition/status. Nurse will be using multiple resources we have to achieve successful completion of the cases. Compelling Story & Candidate Value Proposition What makes this role interesting? Points about team culture Competitive market comparison Unique selling points Value added or experience gained We pride ourselves in having a very cohesive team because we offer a lot of opportunities for the nurses to work closely with each other and have fun with each other as well during our weekly huddles. This is very important because the nurses work from home and do not see each other face to face. We are always open and willing to help each other whenever it is needed. Candidate Requirements Education/Certification Required: RN Preferred: Licensure Required: RN, Preferred: Years of experience required Disqualifiers Best vs. average Performance indicators Must haves: 2-4 years of hospital experience, multi tasking, time management, quick learner, go with the flow attitude, computer savvy
Nice to haves: UM, Clinical/managed care experience
Disqualifiers: unable to multi task, disorganized, not willing to make calls, not computer savvy
Performance indicators: Will be monitoring productivity daily Top 3 must-have hard skills Level of experience with each Stack-ranked by importance Candidate Review & Selection 1 TX RN license or compact state license 2 Communication skills 3 Documentation/Computer skills Candidate Review & Selection Shortlisting process Second touchpoint for feedback Interview Information Onboard Process and Expectations Projected HM Candidate Review Date: Number and Type of Interviews: 1 interview only with supervisors & manager Extra Interview Prep for Candidate: Required Testing or Assessment (by Vendor): Manager Communication Preferences & Next Steps Background Check Requirements (List DFPS or other specialty checks here) No Do you have any upcoming PTO? I will be off June 28-Aug 1st Colleagues to cc/delegate Bernadette Jimenez, Shelly McDonald-Mercer, Raquel Moreno, Erika Mathews
EEO:
"Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of - Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans."
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Location:
Texas City, TX, United States
Category:
Healthcare Practitioners And Technical Occupations

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