Integrated Transitional Care Nurse, RN (Hybrid Schedule) - Inland Empire Health Plan

Overview:

What You Can You Expect?

 

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

 

Join our dynamic team in the Integrated Transition Care Department! Under visionary leadership, you’ll collaborate with hospitals and Independent Physician Associations to deliver continuous, quality healthcare to our high-risk Members. As the Integrated Transitional Nurse, Rn, you’ll lead risk assessments, oversee reviews, and ensure seamless transitions between care settings. Dive into collaboration with various departments, identifying outliers, and ensuring compliance. Be the liaison between stakeholders, contributing to effective communication and goal achievement. Join us and be a part of revolutionizing transitional healthcare!

Additional Benefits:

Perks!

 

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

• Competitive salary.
• Hybrid schedule.
• CalPERS retirement.
• State of the art fitness center on-site.
• Medical Insurance with Dental and Vision.
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development.
• Wellness programs that promote a healthy work-life balance.
• Flexible Spending Account – Health Care/Childcare
• CalPERS retirement
• 457(b) option with a contribution match
• Paid life insurance for employees
• Pet care insurance

Key Responsibilities:

1. Conduct Integrated Transition Care discharge risk assessment for high risk/ high acuity Members.
2. Oversee and perform concurrent and retrospective reviews for medical necessity per evidenced based criteria, appropriateness of service and level of care, either through Telephonic review, clinical documentation submitted by respective facilities and/or electronic medical records (EMR) access.
3. Conduct reviews to ensure Member’s treatment plan is consistent with Diagnosis(es), specifically initial review within twenty-four (24) hours to ensure Members meet specified criteria for the respective admission(s).
4. Work in collaboration with the coordinator to ensure timely arrangements for transitions to higher or lower level of care and assist with transfer orders as needed.
5. Ensure the concurrent or retrospective review process include referring cases that require clinical consultation with the medical director in a timely manner.
6. Ensure cases are appropriately referred to Care Management, Behavioral health, Health Education, Housing, community health.
7. Identify outliers and prepare documentation as well as report on potential quality of care issues as identified.
8. Process timely completion of denials process per policy. The RN will review variances in cases followed by an LVN for possible consultation with the Medical Director to determine approval for due to medical necessity or denial of days.
9. Conduct timely compliance and completion of documents per regulatory requirements.
10. Serve as the IEHP Liaison between hospitals, IPAs vendors, outside agencies and provider to ensure effective communication and collaboration in an effort to meet the Member's treatment plan and goals.
11. Oversee verification of delivery of ordered Durable Medical Equipment (DME), Health Home visits, set up hospital follow up visits with PCP, review of Medications with Member and transportation needs.
12. Oversee and complete Discharge planning assessment.
13. Perform medication reconciliation based on acuity and type of medications.
14. Outreach to Member post discharge to ensure Member attended follow up appointment, Health Home starts visits, possible in-home visit by RN or assigned LCSW as appropriate.
15. Generate additional follow up needed to assign to appropriate regional Behavioral Health & Care Management team.

Qualifications:

Education & Requirements  

 

• Two (2) or more years of Utilization Management / Case Management in a health care delivery setting in Acute or Skilled nursing, with an emphasis on Concurrent Review and Utilization Management.
• Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required
• Must have a valid California Driver's license and valid automobile insurance
• Must qualify and maintain driving record to drive company vehicles based on IEHP insurance standards of no more than three (3) points

 

Key Qualifications

• Knowledge of evidence based clinical criteria and California Children Services (CCS).
• Must have analytical skills. Excellent communication, interpersonal and organizational skills. 
• Self-starter and a team player. Time management, and problem-solving abilities. Must have a high degree of patience.

 

Start your journey towards a thriving future with IEHP and apply.

Work Model Location:

Candidates must be flexible to travel 5 days/week to hospitals and skilled nursing facilities.

Pay Range:USD $43.87 - USD $58.13 /Hr.