Organizational Description

The Community Health Center Network (CHCN), sister organization to the Alameda Health Consortium, is made up of the eight federally qualified community health centers in Alameda County. CHCN functions as the managed care MSO for our health centers, contracting with the Alameda Alliance for Health and Anthem Blue Cross. In order to help our health centers meet their missions of providing the best possible care to their communities, we also provide a broad range of training, technical assistance, quality improvement, information technology, and data analytic services.

Position Title: Inpatient Care Transitions (ICT) Nurse

Department: Care Management

Reports To: Inpatient UM Supervisor

Classification: Non-Exempt

Status: Full-Time Regular

Salary Range: $43.80 hour to $52.79 hour

POSITION SUMMARY

Proactively conduct on-site concurrent and retro reviews of inpatient utilization according to CHCNs clinical criteria guidelines. Implement and assist in the utilization management processes, according to departmental policies and procedures. Case Manage patients with complex post-acute care needs according to the Care Transitions model. Coordinate with clinics and outside agencies to facilitate discharge planning of patients. Responsible for denial letters required by HMO contracts and other parties.

ESSENTIAL POSITION RESULTS

The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks and responsibilities. Employees may perform other duties as assigned.

Manage and coordinate in-patient review and discharge planning and case management activities related to immediate post-discharge needs.

Train in and implement Care Transitions model in discharge planning; participate in diffusion of model in clinic setting.

Support proactive hospital discharge planning, transfers, and redirection.

Proactively and collaboratively, interface with medical director, HMOs, clinic and facility staff, outside agencies, member and their families to assist in expediting appropriate discharge and coordination of care.

Meet departmental review and documentation standards for work assignments.

Write denial letters, and other Notices of Action, to member/providers using HMO templates.

Serve as a liaison between hospital, clinics, health plan, vendors, outside agencies, and providers.

Work with health plans on special requests such as obtaining ancillary services from non-contracting providers.

Assist UM Director in the periodic review and update of UM/Case Management policy and procedures, and in the ongoing evaluation and improvement of workflow systems for UM.

Coordinate completion and send required UM monthly reports to Health Plans, as assigned

HIPAA Designated Access

For the purposes of the job duties of this position, the person in this position requires access only to the following HIPAA protected information data sets

1. MSO Membership 2. MSO Claims 3. MSO Referral/Auth. 4. MSO Capitation

5. Data Warehouse 6. Chart Audit/QI 7. Disease Registry

SUPERVISORY RESPONSIBILITIES

None

MINIMUM QUALIFICATIONS

Competencies

Competent leadership and administrative skills.

Good communication and customer relations skills; ability to work well with a team and independently.

Utilization Management and Case Management experience; understanding and knowledge of healthcare benefits associated with various business lines (Medi-Cal, Medicare, Commercial).

Inpatient concurrent review, especially working with complex medical patients, including aged, blind, disabled.

Ability to work independently in most instances, requiring limited supervision.

Proficiency in computer operations and comfortable with Internet-based applications. Fundamental word processing and computer navigation skills.

Sound decision-making skills including problem solving, critical thinking, and good clinical judgment for clinical and non-clinical issues.

Logical, independent thinker.

Professional demeanor.

Essential Requirements

1 year Utilization Management in hospital, HMO, or IPA setting.

1 year in health care delivery setting at hospital, clinic or physicians office.

Strong understanding of the managed care environment.

Will considered new graduates from Masters in Case Management Program(s)

CERTIFICATES AND/OR LICENSES

Current and Unrestricted RN License

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this Job, the employee is regularly required to sit and use hands to finger, handle, or feel. The employee is frequently required to talk or hear. The employee is frequently required to stand; walk; reach with hands and arms and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus.

WORKING CONDITIONS AND ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly exposed to an inside environment.

The Community Health Center Network is an Equal Opportunity Employer.