Job Profile Summary
Position Purpose:
Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.
Education/Experience:
Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required.
Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred.
Knowledge of Medicare and Medicaid regulations preferred.
Knowledge of utilization management processes preferred.
License/Certification:
LPN - Licensed Practical Nurse - State Licensure required
For Health Net of California: RN license required
Responsibilities
Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care
Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member
Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered
Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines
Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings
Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members
Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines
Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities
Collaborates with care management on referral of members as appropriate
Performs other duties as assigned
Complies with all policies and standards
EEO:
“Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of – Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.”
Story Behind the Need
- What is the purpose of this team?
- What is driving this need? (ex. Backfill for FTE or CW, new project, business growth)
- Describe the surrounding team (team culture, work environment, etc.) & key projects.
- Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?
Backfill for temporary worker that resigned plus 2 new positions
Typical Day in the Role
- Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD).
- What are performance expectations/metrics?
- What makes this role unique?
- Review clinical charts for medical necessity for inpatient admissions
- Review concurrently as long as they remain in-house/inpatient until discharged
- Utilize InterQual to review medical necessities
- Make appropriate referrals for members depending on their clinical presentation
- No direct communication to members
Candidate Requirements
Education/Certification
Required: Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2-4 years of related experience
Preferred:
Licensure
Required: Registered Nurse or LPN License
Preferred: Registered Nurse License - compact
Years of experience required: Requires at least two years of Acute Care or ICU care experience.
Disqualifiers: No Acute Care or ICU care experience
Additional qualities to look for: adaptable, flexible, good time management skills, team player
- Top 3 must-have hard skills stack-ranked by importance
1
Minimum of 2 years of Acute or ICU clinical experience
2
Organizes and prioritizes effectively
3
Problem-solving skills
Candidate Review & Selection
- Shortlisting process
- Candidate review & selection
- Interview information
- Onboard process and expectations
Projected Manager Candidate Review Date:
1-2 days post shortlisting
Type of Interviews:
Teams – camera on
Required Testing or Assessment (by Vendor):
Next Steps
- Do you have any upcoming PTO?
No
- Colleagues to cc/delegate
