SUMMARY: Performs onsite or telephonic clinical review for the acutely hospitalized Monarch HealthCare member or member in the Skilled Nursing Facility environment. Actively implements a plan of care utilizing approved clinical guidelines to transition and provide continuity of care for the member to an appropriate lower level of care in collaboration with the hopitalist/physician team, acute or skilled facility staff, ambulatory care team, and the member and/or member's representative from admission through discharge.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
1. Performs concurrent and retrospective onsite or telephonic clinical review at the designated network or out-of-network facilities as needed/directed by the ICPS Management team (Director, Manager, and Supervisors) documenting medical necessity and appropriate level of care utilizing clinical guidelines (e.g. Milliman, Interqual). Complies with CMS regulations and Health Plan requirements.
2. Interacts and effectively communicates with members, their families and/or designated member representative to assess discharge needs and formulate discharge plan, provide Health Plan benefit information, and services available based on clinical need.
3. Interacts daily with treating physicians regarding the Monarch HealthCare member's plan of care and alternative care solutions. Consults the Monarch Medical Director/designee for unusual and complex cases.
4. Effectively communicates plan of care to facility staff, health plan partners, and Ambulatory Case Management (ACM) to ensure understanding treatment plan and clinical needs at time of transition to lower level of care.
5. Efficiently navigates and utilizes computer data entry programs including, but not limited to: Microsoft Office (Outlook, Word, and Excel), RightFax, Adobe Reader for fax attachment process.
6. Provides guidance and benefits information for members and their families and facility discharge planners.
7. Documents and maintains a Continuity Plan of Care for the Monarch HealthCare member by assessing and identifying continued needs upon discharge to encompass; health services, durable medical equipment, hospice, follow-up physician appointments, skilled versus sub-acute versus custodial levels of care.
8. Issues the appropriate denial letters based on Health Plan or CMS guidelines utilizing ICE language.
9. Identifies and reports all institutionalized, ESRD and hospice patients, and appropriately refers members with special transition needs or disease management to ACM.
10. Performs on call duties as scheduled on a rotating basis.
11. Identifies Quality Improvement (QI) indicators and provides timely reporting to the QI department.
12. Actively participates in the orientation and ongoing training of new employees as needed.
13. Actively participates in the ongoing development of IPCS by participating in task forces for policy and procedure review/revision/development, staff meetings, and other departmental meetings/committees promoting Monarch HealthCare's core ideals and values.
EDUCATION and/or EXPERIENCE: Graduate of an accredited School of Nursing. BSN or equivalent desirable. Minimum of 3 years recent acute care or managed care experience. Current and valid, unrestricted California state nursing license. CCM preferred.
LICENSES, CERTIFICATES, REGISTRATIONS: Current State of California Registered Nursing License. CCM or CPUR preferred. Current/valid California Driver's License with current insurance.
Skills / Requirements