IP Clinical Nurse Lead

Medical/Healthcare Oakland, California


Description


At Brown & Toland we’re the people behind the scenes who make sure our Physicians have the time and support to do what they do best- care for our members. Together, we form one of the most recognized medical groups in the California. We are 2,700+ local physicians, working in 38 cities in California, caring for more than 350,000 patients. If working with highly competent, hard-working, thoughtful clinicians who value good ideas and are passionate about reshaping healthcare excites you, then we’re thrilled to welcome you to your new career.

 

POSITION SUMMARY:

The Inpatient Lead Care Manager RN is a content expert and resource for the IP concurrent review department including authorizations and or denial processes. Discharge planning and transition of care services for hospitalized Brown & Toland members. Performs admission and concurrent review using nationally recognized criteria, including severity of illness and intensity of services based on MCG, Responsible for care coordination and identification of post-acute level of care including home health, skilled nursing and acute rehabilitation services. Identification of members hospitalized out of network and arranging repatriation as appropriate.

 

ESSENTIAL JOB FUNCTIONS:

  • Through understanding of managed health care models inclusive of shared and global risk arrangements. Understanding of state and federal regulatory requirements related to Commercial, State and Federal products. 
  • Through onsite or electronic concurrent review will assess, plan, implement, coordinate, monitor and evaluate the options and services needed to meet the member’s health needs across the care continuum and provide quality, cost-effective outcomes
  • Assure that members are at the appropriate level of care from admission through discharge and provide timely discharge planning.
  • Utilize clinical knowledge, problem solving and decision-making skills to evaluate requests for authorization which includes screening for appropriateness, verifying eligibility, interpretation of benefits and medical necessity
  • Researching issues to facilitate objective medical management decisions based upon approved criteria, standards and guidelines
  • Regular communication with internal and external partners for clinical decisions regarding medical necessity and timely access to care
  • Assess and triage patients, providing concise SBAR to medical directors to support decision-making
  • Conduct clinical review as required by Health plan delegation agreement to resolve challenges and service denials
  • Issues facility denial letters as appropriate to the hospital
  • Provide case management activities across the continuum of care in order to facilitate and promote high quality, cost effective outcomes
  • Assist in the development, implementation and evaluation of care standards, policies, procedures and protocols to improve Care Management across the care continuum
  • Participate in employee training/orientation and mentoring of team members as indicated

 

QUALIFICATIONS & REQUIREMENTS:

  • Ability to read and understand inpatient medical records and extract data pertinent to the projected trajectory of a member’s hospital course and compare it to nationally recognized treatment standards
  • Effective verbal and written communication skills, to represent the organization and be a patient advocate; Internal and external customer focused.
  • Working knowledge of utilization management, reimbursement, medical necessity criteria including InterQual. Knowledge of managed care concepts, Medicare/Medi-Cal Guidelines.
  • Health Plan and or Medical Group experience preferred
  • A strong understanding of health plan benefits and the ability to formulate an effective discharge plan and communicate it to the various stakeholders

 

EDUCATION AND/OR TRAINING:

  • Bachelor of Nursing degree preferred
  • Current California unrestricted RN license required
  • Advanced computer skills including electronic medical records, Outlook email, and Microsoft Office suite
  • Minimum of three (3) years recent acute clinical experience required in a hospital setting.
  • Managed Care experience
  • Discharge planning experience preferred in an acute care