Perform concurrent reviews of members for appropriate care and setting to determine overall health and appropriate level of care.
Review quality and continuity of care by assessing acuity level, resource consumption, length of stay, and discharge planning of members.
Collaborate with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered.
Collect, document, and maintain concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines.
Work with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings.
Assist with providing education to providers on utilization processes to ensure high-quality appropriate care to members.
Provide feedback to leadership on opportunities to improve appropriate level of care and medical necessity based on clinical policies and guidelines.
Review member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities.
Collaborate with care management on referral of members as appropriate.
Perform other duties as assigned.
Comply with all policies and standards.
Requirements:
Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing.
Minimum 2 years of acute care experience required.
LPN - Licensed Practical Nurse - State Licensure required.
For Health Net of California: RN license required.
Preferred Skills:
Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care.