Concurrent Review Nurse

JOB SUMMARY: Registered Nurse or Licensed Practical Nurse responsible for clinical review of all hospital services for appropriateness based on medical criteria.  This individual is responsible for the management of inpatient resources necessary and appropriate for achievement of desired inpatient outcomes and the coordination of alternative levels of care for membership.

 

PRIMARY RESPONSIBILITIES:

1.  Performs on-site and/or telephonic review of inpatient services within one business day of admission

2.  Predicts and plans for patient?s needs from pre-admission, through inpatient care and post-discharge

3.  Utilizes preapproved criteria and guidelines to validate medical necessity of continued stay and appropriateness of treatment and discharge planning

4.  Acts in conjunction with the Medical Director and the Director of Medical Management on a daily basis to assess the inpatient census for appropriate alternative heath care service needs.

5.  Coordinates with appropriate discharge planning team members, hospital utilization management department, and  physicians to coordinate timely inpatient discharges

6.  Strives to maintain quality care while minimizing resource usage and decreasing inpatient length of stay

7.  Identifies and reports any quality or utilization issues to the Medical Director

8.  Acts in conjunction with the Health Plan Case Managers related to discharge planning e.g., home care, hospice care, rehabilitation care, special program care, transitional care, occupational therapy, speech, respiratory and physical therapy, durable equipment and disposable supplies

9.  Documents all concurrent reviews in the Amysis system on a daily basis.  Updates and closes out all hospital admissions at time of discharge

10.  Participates in daily rounds with the Medical Director.  Presents criteria based report of patient status

11.  Conducts retrospective inpatient reviews when requested

12. Other duties as requested or assigned.

 

PLEASE APPLY ONLINE AT http://www.amerigroupcorp.com/corporate/work_for_us.asp

 

JOB REQUIREMENTS:

 

Education and Experience:

?  HMO experience preferred.

?  Minimum of 3 years hospital/acute care experience

?  2 to 3 years of prior clinical experience in UM

?  Discharge Planning, Community Health Experience a plus

 

Certification and Licensure:

?  RN or LPN licensed to practice in the State.

 

Knowledge and Skills:

?  Multi-tasked oriented

?  Ability to handle complex clinical situations with emphasis on managed care

?  Self-confidence, ability to deal sensitively and diplomatically with difficult situations

?  Appreciation of cultural diversity and sensitivity towards target population

?  Computer literate

?  Bilingual a plus

?  Excellent communication skills, both verbal and written.

?  Problem-solver

?  Appreciation of cultural diversity and sensitivity towards target population.

 

Physical Requirements:

?  Must be able to operate a computer.

?  Must be able to operate a telephone.

?  Must have a valid driver?s license and access to a motor vehicle

 

PLEASE APPLY ONLINE AT http://www.amerigroupcorp.com/corporate/work_for_us.asp