Job description
Job Description
Location: California
Employment Status: Full time
General Statement of Duties
This position coordinates concurrent review and case management activities for commercial and Medicare enrollees. The concurrent review nurse is knowledgeable about the Nurse Practice Act, JCAHO, NCQA, HMO and Medicare rules and pertinent state and federal regulations. The concurrent review nurse works as a team member in cooperation with the Medical Directors, UR RNs, benefits coordinators, hospital discharge planners and health plan reviewers.
Essential Functions and Responsibilities
- Reviews and actively manages all acute and skilled nursing facility inpatient stays in accordance with NCQA timeliness standards and health plan benefit structure
- Determines medical necessity and length of stay based on the consistent application of MCG criteria and communicates with Medical Directors for those reviews that fall outside of approvals
- Ensures that services provided are within benefit plan and appropriate contracted providers are being utilized
- Educates and supports members in the accessing care using their HMO and Medicare benefits as needed
- Identifies and refers patients to care management program whenever relevant
- Performs other duties that may be assigned from time to time
Job Requirements
- Current California RN License with no restrictions
- Bachelor Science Degree, Nursing
- Five years of clinical experience and two years of experience in Managed CareOrganization, health plan utilization management, Commercial HMO or Medicare,preferred.
- Ability to understand and facilitate communication among team members, patients,families and physicians
- Ability to communicate effectively with health plans and outside agencies
- Good clinical judgment, critical thinking skills and independent problem resolution
- Ability to organize and prioritize workload to meet required turnaround times
- Basic proficiency using a PC in a Windows environment, including Microsoft Word, Exceland Electronic Medical Records
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