Key Responsibilities:

1. Conduct Integrated Transition Care discharge risk assessment for high risk/ high acuity Members.
2. 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.
3. 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).
4. 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.
5. Ensure the concurrent or retrospective review process include referring cases that require clinical consultation with the medical director in a timely manner.
6. Ensure cases are appropriately referred to Care Management, Behavioral health, Health Education, Housing, community health.
7. Identify outliers and prepare documentation as well as report on potential quality of care issues as identified.
8. Process timely completion of denials process per policy. The RN will review variances in cases followed by an LVN for possible consultation with the Medical Director to determine approval for due to medical necessity or denial of days.
9. Conduct timely compliance and completion of documents per regulatory requirements.
10. Serve as the 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.
11. 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.
12. Oversee and complete Discharge planning assessment.
13. Perform medication reconciliation based on acuity and type of medications.
14. Outreach to Member post discharge to ensure Member attended follow up appointment, Health Home starts visits, possible in-home visit by RN or assigned LCSW as appropriate.
15. Generate additional follow up needed to assign to appropriate regional Behavioral Health & Care Management team.

Education & Requirements

• 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


• Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required


• Yes, must have a valid California Driver's license and valid automobile insurance


• Must qualify and maintain driving record to drive company vehicles based on insurance standards of no more than three (3) points

Key Qualifications

• Knowledge of evidence based clinical criteria and California Children Services (CCS)


• Must have analytical skills. Excellent communication, interpersonal and organizational skills


• Self-starter and a team player


• Time management, and problem-solving abilities


• Must have a high degree of patience