Onsite Concurrent Review Nurse
Onsite Concurrent Review Nurse
Description:
Proactively manage inpatient and/or skilled nursing utilization to assure that medical care is appropriate, efficient, and medically necessary. Support facility discharge planning efforts, transfers and coordination of care in the San Leandro/Eden area.
Responsibilities:
- Conduct onsite concurrent review of inpatient utilization at assigned facilities according to clinical criteria, and diligently complete retrospective review within specific time frames. Support proactive facility discharge planning, transfers, and redirection while identifying barriers to efficient hospital utilization and facilitate resolution. Reduce avoidable bed days use by applying applicable criteria and properly documenting decisions and issuing related correspondence.
- Proactively and collaboratively interface with HMOs, physicians, internal staff, members and their families to assist in expediting appropriate discharge, including related bedside visits and post-discharge calls to members. Persuade hospital staff and physicians to adopt appropriate behavior to facilitate efficient and effective inpatient utilization while supporting a positive work environment and fostering teamwork.
- Abide by and maintain telecommuting standards and adhere to the policy and procedures of assigned hospital(s). Also, meet CCR attendance and availability standards.
- Refer members to various other departments (i.e., Case Management, Disease Management, TPL, COB) for follow-up as appropriate.
- Meet departmental review and documentation standards for work assignments while supporting AMS (Affinity Medical Group) authorizations process, clinical initiatives, and other activities.
- Properly request letters, including applying the appropriate legal and regulatory requirements for ICE and health plan specific letter Templates.
- Serve as a liaison between the hospital, health plan, vendors, and providers while managing individual market to determine opportunities to improve utilization, quality of care, access issues and physician profiling. Build and maintain appropriate relationships on behalf of AMS.
Required Experience:
- Three years of Medical/Surgical clinical nursing experience
- Managed-care experience and or certification preferred
- Proficient in Microsoft Office applications and other computer skills
- Excellent communication, organizational and time management skills with the ability to meet tight timeframes
- Ability to work effectively and collaboratively with a variety of customers including physicians, health plans, hospital/office staff, providers, and members
- Physically capable to go onsite and work in hospital environment, requiring lengthy walking, standing and carrying medical records
- Ability to work independently and apply critical thinking skills towards making appropriate decisions
- Ability to travel to work assignments
- Flexible and adaptable to change
- Ability to learn quickly and retain complex information
Required Licenses/Insurances:
- Active, unrestricted California Nursing License required. Registered or Licensed Vocational Nurse.
- Valid CA Driver’s License
- Car Insurance