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.”
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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.
INPT ACUTE and POST ACUTE experience preferred
MUST BE RN COMPACT license or willing to get.
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
Story Behind the Need
Newer and Growing DUALS Line of Business
Great to be part of the learning and discovery; team process that we work out together; never work alone as we always have team support. Team sups are always involved. Have a lot of resources working with this team. Very flexible and family oriented.
- Hiring 12 external 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?
- Work in tru care cloud & classic; working from work ques; utilization management; review cases for medical inpatient (hospital/rehab) (dual-medicare/Medicaid)
- Metrics: work in progress because we do both LOBS (we conduct 2 reviews on one case). Must be doing 2 reviews/hour in a 6-month timeframe
Centene’s DUALS :we want to see it succeed so it will be exciting to be a part of it.
Candidate Requirements
Required : Required: Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing
and 2 – 4 years of related experience
Required : Compact licensure OR willing to acquire a required Compact state license. Willing to obtain other state licensure if needed at company expense
Required : Required: RN - State Licensure
Preferred:
Years of experience required: Years of experience required:
- 2+ years of acute care experience required
- 2 – 4 years of related experience
Disqualifiers:
- Top 3 must-have hard skills stack-ranked by importance
1
Additional qualities to look for:
Utilization Management & Clinical Assessment
- Ability to perform real‐time (concurrent) review of inpatient cases
- Strong understanding of medical necessity guidelines, such as InterQual or MCG
- Skilled at interpreting clinical documentation and determining appropriate levels of care
- Problem solve and Triage duties
2
Communication & Care Coordination
• Clear, concise communication with providers, care teams, and insurance representatives
• Ability to advocate for appropriate care while maintaining positive provider relationships
• Skilled at documenting clinical findings and review decisions accurately and timely
3
1-2 days post shortlisting
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
Required Testing or Assessment (by Vendor):
N/A
