Integrated Transitional Care, RN - CCA 4/10 Weekend - Inland Empire Health Plan

Overview:

What you can 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!

 

Under the direction of the Supervisor, UM Inpatient & Specialty - CCA, the incumbent will work with Hospitals and Independent Physician Association (IPA) with their assigned Team Center to initiate coordinated and continuous cost-effective quality healthcare to ensure the continuity of the Member’s care needs are met timely throughout the admission and readmission prevention for our high-risk Members. This will be accomplished through concurrent review processes using nationally recognized criteria. The Integrated Transitional Care Nurse, RN - CCA will participate in providing transitional care services to the Members with each transition from one care setting to the next.

 

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Additional Benefits:

Perks

 

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

 

• CalPERS retirement
• 457(b) option with a contribution match
• Generous paid time off- vacation, holidays, sick
• State of the art fitness center on-site
• Medical Insurance with Dental and Vision
• Paid life insurance for employees with additional options
• Short-term, and long-term disability options
• Pet care insurance
• Flexible Spending Account – Health Care/Childcare
• Wellness programs that promote a healthy work-life balance
• Career advancement opportunities and professional development
• Competitive salary with annual merit increase
• Team bonus opportunities

Key Responsibilities:

1. 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.
2. 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).
3. 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.
4. Ensure the concurrent or retrospective review process include referring cases that require clinical consultation with the medical director in a timely manner.
5. Ensure cases are appropriately referred to Care Management, Behavioral health, Health Education, Housing, community health.
6. Identify outliers and prepare documentation as well as report on potential quality of care issues as identified.
7. Process timely completion of denials process per policy. 
8. Conduct timely compliance and completion of documents per regulatory requirements.
9. 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.
10. 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.
11. Oversee and complete discharge planning.
12. Perform medication reconciliation based on acuity and type of medications.
13. Generate additional follow up needed to assign to appropriate regional Behavioral Health & Care Management team.
14. Any other duties as required ensuring Health Plan operations are successful.

Qualifications:

Education & Experience

• 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. Experience with Commercial Plan Coverage required
• High school diploma or GED required
• Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required

 

Key Qualifications

• 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
• Knowledge of evidence based clinical criteria and California Children Services (CCS)
• Knowledge of Commercial Managed Care coverage required

 

 

Start your journey towards a thriving future with IEHP and apply TODAY!

Work Model Location:

Telecommute

Pay Range:USD $38.37 - USD $48.93 /Hr.