Remote Utilization Review Nurse Jobs

The Inpatient Review Nurse assists patients through the continuum of care in collaboration with the patient's primary care physician, facility case manager, discharge planner and employing contracted ancillary service providers and community resources as needed. Assures that services are provided at the most appropriate, cost effective level of care needed to meet the patient's medical needs while maintaining safety and quality.

GENERAL DUTIES/RESPONSIBILITIES

• Performs reviews of inpatients with complex medical and social problems.
• Generates referrals to contracted ancillary service providers and community agencies with the agreement of the patient's primary care physician.
• Performs follow-up reviews and evaluations of patients in the ambulatory care or lower level of care setting.
• Reviews inpatient admissions timely and identifies appropriate level of care and continued stay based on acceptable evidence-based guidelines used by AHC.
• Effectively communicates with patients, their families and or support systems, and collaborates with physicians and ancillary service providers to coordinate care activities.
• Identifies Members who may need complex or chronic case management post discharge and warm handoff to appropriate staff for ambulatory follow up, as necessary.
• Communicates and collaborates with IPA/MG as necessary for effective management of Members.
• Assigns and provides daily oversight of the activities and tasks of the CCIP Coordinator.
• Records communications in EZ-Cap and/or case management database.
• Arranges and participates in multi-disciplinary patient care conferences or rounds.
• Monitors, documents, and reports pertinent clinical criteria as established per UM policy and procedure.
• Monitors for any over utilization or underutilization activities.
• Generates referrals as appropriate to the QM department.
• Enters data as necessary for the generation of reports related to case management.
• Reports the progress of all open cases to the Medical Director, Director of Healthcare Services and Manager of Utilization Management.
• Performs other duties as assigned.

Minimum Requirements

Experience

• Required: Minimum 3 years of general case management skills. Minimum of two years of experience utilizing Milliman Care Guidelines to justify Inpatient versus Observation Length of stay: including review of diagnosis and length of stay. Two consecutive years related experience in a managed care setting as an inpatient case manager

• Preferred: Experience with a Senior population.

Education

• Required: Successful completion of an accredited Licensed Vocational Nursing Program

• Preferred: Associates or Bachelors Degree

Specialized Skills

• Required

• Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
• Excellent critical thinking skills related to nursing utilization review
• Knowledge of Medicare Managed Care Plans
• Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
• Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly
• Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Report Analysis Skills: Comprehend and analyze statistical reports.

• Preferred: Knowledge and experience in complex/catastrophic case management preferred

Licensure

• Required: Current, Active and Unrestricted California Licensed Vocational Nurse.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.

Essential Physical Functions

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1 While performing the duties of this job, the employee is regularly required to sit; use hands to finger, hand, or feel and talk or hear.

2 The employee is frequently required to reach with hands and arms

3 The employee is occasionally required to climb or balance and stoop, or kneel

4 The employee must occasionally lift and/or move up to 20 pounds.

5 Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

Pay Range: $77,905.00 - $116,858.00

Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.