CLINICAL PROGRAMS RN

JOB PURPOSE: Responsible for managing a participant’s successful transition from hospital to home or other care setting. Accountable for overall care management, discharge planning and quality of care for participants. Responsible for managing the post-acute care of high-risk participants that are at risk for poor health outcomes, frequent emergency room visits and hospital readmissions. Responsible for reviewing, recommending, and providing authorization for services requested by providers based on evidence based medical necessity criteria. JOB RESPONSIBILITIES: TOC (Transitions of Care) duties: Collaborates with hospitals, medical providers, caregivers, participants, families, other departmental team members, and payors to proactively develop and implement a safe and appropriate discharge plan from the hospital or emergency department. Collaborates with Nursing Home Staff and the IDT to proactively develop and implement services or programs to help reduce hospital readmissions or ED visits for participants from the community, long term care or subacute rehab setting. Participates in team meetings that foster interdepartmental collaboration with the patient and their family as deemed necessary, this includes multidisciplinary meetings and Clinical Review/Case Management meetings. Participate in and ensures completion of discharge assessments and follow up phone calls are in a timely manner. Provides care management services across sites and collaborates with appropriate team members, facility, discharge planner and/or home care coordinator when members are transitioned between care settings. Documents services in accordance with CLHC standards and federal/state regulations. Collaborates with PCP and other specialty providers and specialty-based services and members of IDT regarding any changes in participants condition to secure, arrange and coordinate all resources for implementing optimal care. Provides reviews for acute and subacute rehab requests based on evidence-based medical necessity criteria Recommends and contributes to improvements in services, programs, policies, and procedures, to ensure optimum care and services to members. All other duties as assigned. High Risk-High Impact (HR-HI) panel duties: Assist with quarterly updates to provider HR-HI panels. Participate in provider HR-HI panel case reviews. Communicate HR-HI review recommendations to provider and the IDT. Clinical Review duties: Processes requests for authorization from in-network providers and communicates in a timely manner when the decision has been made by the Interdisciplinary Team (IDT). Collects, reviews, and evaluates information necessary to reach prospective, concurrent and retrospective decisions using objective evidence-based clinical criteria. Suggests alternate care plans, makes recommendations and coordinates with the Provider/IDT for appropriate utilization of services Documents case reviews, associated communications, and outcomes in the electronic case file. Presents cases to the site Physician and/or Medical Director for review and determination. Works closely with the Physician and/or Medical Director to ensure that medical review of specific cases occurs timely and meets standards for decision turnaround times. Participates in periodic inter-rater reliability testing on medical necessity criteria application. Recognizes and refers potential quality of care concerns to Quality Management. Maintains confidentiality of all information in compliance with State and Federal Law and CenterLight Healthcare policy. Identifies and communicates system improvements or individual care issues that would cause failure to provide appropriate care or meet service requirements. Performs other duties as assigned. Schedule: 8:30AM – 5:30PM Weekly Hours: 40 QUALIFICATIONS: Education: BSN required Experience: Minimum of three to five (3 - 5+) years’ experience in a hospital or home care clinical setting. Knowledgeable about Medicare and Medicaid guidelines. Case Management and discharge planning experience is beneficial. Two to three (2 - 3) years of Utilization Review experience at a Managed Care Organization is preferred. Physical Requirements Individuals must be able to sustain specific physical requirements essential to the job. This includes, but is not limited to: Standing – duration of up to 6 hours a day. Sitting/Stationary positions – sedentary position for up to 6-8 hours a day for consecutive hours/periods of time. Lifting/Push/Pull – up to 50 pounds of equipment, baggage, supplies, and ability to lift patients safely, using OSHA guidelines, etc. Bending/Squatting – have to be able to bend or squat to care for patients safely, use medical supplies, etc. Stairs/Steps/Walking/Climbing – must be able to maneuver stairs safely, climb up/down and walk to access work areas Position requires an individual to be able to travel, walk between sites/locations and work areas throughout the day. Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools (i.e., typing, use of medical supplies, equipment, etc.) Sight/Visual Requirements – must be able to visually assess patients, read orders and type/write documentation, etc., accurately. Audio Hearing and Motor Skills (language) Requirements – must be able to listen attentively and document information from patients, community members, providers, etc., and intake information through audio processing with accuracy. In addition, must be able to speak comfortably and clearly with language motor skills for customers to understand the individual. Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job. Disclaimer: Responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of the company. We are an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information. We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities. Salary Range (Min-Max): $100,000.00 - $115,000.00 Every application is reviewed by our recruitment team. We do not use AI to make hiring decisions or automatically reject applicants. All employment decisions are based on job-related qualifications and applicable employment laws. CenterLight Healthcare System currently hires employees in states where we are registered to do business. At this time we are able to consider candidates residing in the following states: Alabama California Colorado Connecticut Florida Georgia Illinois Louisiana Massachusetts New Jersey New York North Carolina Ohio Oklahoma Oregon Pennsylvania Puerto Rico South Carolina Texas Utah Virginia Wisconsin