Alura Workforce Solutions
Integrated Transitional Care Nurse, RN 24-00400
Alura Workforce Solutions, Rancho Cucamonga, California, United States, 91739
Overview
Integrated Transitional Care Nurse, RN – Hybrid schedule. Join our dynamic team in the Integrated Transition Care Department. Under leadership, you will collaborate with hospitals and Independent Physician Associations to deliver continuous, quality healthcare to high-risk Members. As the Integrated Transitional Nurse, RN, you will lead risk assessments, oversee reviews, and ensure seamless transitions between care settings. You will collaborate across departments, identify outliers, and ensure compliance. Serve as a liaison between stakeholders to support effective communication and achievement of goals in transitional healthcare. Responsibilities
Conduct Integrated Transition Care discharge risk assessment for high risk/high acuity Members. Oversee and perform concurrent and retrospective reviews for medical necessity per evidence-based criteria, appropriateness of service and level of care, through telephonic review, clinical documentation from facilities and/or electronic medical records (EMR). Conduct reviews to ensure Member\'s treatment plan aligns with diagnoses, including initial review within 24 hours to ensure criteria for admission are met. Collaborate with the coordinator to arrange timely transitions to appropriate levels of care and assist with transfer orders as needed. Ensure the review process includes timely clinical consultation with the medical director when needed. Refer cases to Care Management, Behavioral Health, Health Education, Housing, and community resources as appropriate. Identify outliers and prepare documentation; report potential quality of care issues identified. Process denials per policy; review variances in cases with LVN consultation with the Medical Director to determine medical necessity or denial of days. Complete compliance and documentation per regulatory requirements. Act as liaison between hospitals, IPAs, vendors, and providers to ensure effective communication and collaboration around the Member\'s treatment plan and goals. Oversee verification of DME delivery, Health Home visits, scheduling follow-up visits with PCP, review of medications with the Member, and transportation needs. Oversee and complete discharge planning assessment. Perform medication reconciliation based on acuity and medication types. Outreach to Members post-discharge to ensure attendance at follow-up appointments, Health Home involvement, and appropriate in-home visits as needed. Coordinate with regional Behavioral Health & Care Management teams for additional follow-up as necessary. Requirements
Two (2) or more years of Utilization Management / Case Management in a health care delivery setting in Acute or Skilled Nursing, with emphasis on Concurrent Review and Utilization Management. Active, unrestricted RN license issued by the California BRN required. Valid California driver\'s license and automobile insurance. Must qualify and maintain driving record to drive company vehicles (no more than three points). Knowledge of evidence-based clinical criteria and California Children Services (CCS). Analytical skills with excellent communication, interpersonal and organizational abilities. Details
Title: Integrated Transitional Care Nurse, RN Position Type: Hybrid Schedule: Monday–Friday, 8:00 am – 5:00 pm; Work-from-home on Monday and Friday; Onsite Tuesday, Wednesday, Thursday.
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Integrated Transitional Care Nurse, RN – Hybrid schedule. Join our dynamic team in the Integrated Transition Care Department. Under leadership, you will collaborate with hospitals and Independent Physician Associations to deliver continuous, quality healthcare to high-risk Members. As the Integrated Transitional Nurse, RN, you will lead risk assessments, oversee reviews, and ensure seamless transitions between care settings. You will collaborate across departments, identify outliers, and ensure compliance. Serve as a liaison between stakeholders to support effective communication and achievement of goals in transitional healthcare. Responsibilities
Conduct Integrated Transition Care discharge risk assessment for high risk/high acuity Members. Oversee and perform concurrent and retrospective reviews for medical necessity per evidence-based criteria, appropriateness of service and level of care, through telephonic review, clinical documentation from facilities and/or electronic medical records (EMR). Conduct reviews to ensure Member\'s treatment plan aligns with diagnoses, including initial review within 24 hours to ensure criteria for admission are met. Collaborate with the coordinator to arrange timely transitions to appropriate levels of care and assist with transfer orders as needed. Ensure the review process includes timely clinical consultation with the medical director when needed. Refer cases to Care Management, Behavioral Health, Health Education, Housing, and community resources as appropriate. Identify outliers and prepare documentation; report potential quality of care issues identified. Process denials per policy; review variances in cases with LVN consultation with the Medical Director to determine medical necessity or denial of days. Complete compliance and documentation per regulatory requirements. Act as liaison between hospitals, IPAs, vendors, and providers to ensure effective communication and collaboration around the Member\'s treatment plan and goals. Oversee verification of DME delivery, Health Home visits, scheduling follow-up visits with PCP, review of medications with the Member, and transportation needs. Oversee and complete discharge planning assessment. Perform medication reconciliation based on acuity and medication types. Outreach to Members post-discharge to ensure attendance at follow-up appointments, Health Home involvement, and appropriate in-home visits as needed. Coordinate with regional Behavioral Health & Care Management teams for additional follow-up as necessary. Requirements
Two (2) or more years of Utilization Management / Case Management in a health care delivery setting in Acute or Skilled Nursing, with emphasis on Concurrent Review and Utilization Management. Active, unrestricted RN license issued by the California BRN required. Valid California driver\'s license and automobile insurance. Must qualify and maintain driving record to drive company vehicles (no more than three points). Knowledge of evidence-based clinical criteria and California Children Services (CCS). Analytical skills with excellent communication, interpersonal and organizational abilities. Details
Title: Integrated Transitional Care Nurse, RN Position Type: Hybrid Schedule: Monday–Friday, 8:00 am – 5:00 pm; Work-from-home on Monday and Friday; Onsite Tuesday, Wednesday, Thursday.
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