Registered Nurse - Utilization Management Pace (Riverside)

Community health is about more than just vaccines and checkups. It's about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We're with you every step of the way, with the care you need for each of life's chapters. At Neighborhood, we are Better Together.

As a private, non-profit 501(C) (3) community health organization, we serve over 500,000 medical, dental, and behavioral health visits from more than 96k people annually. We do this in pursuit of our mission to improve the health and happiness of the communities we serve by providing quality care to all, regardless of situation or circumstance.

We have been doing this since 1969 and it is our employees that make this mission a reality. Regardless of the role, our team focuses on being compassionate, having integrity, being professional, always collaborating, and consistently going above and beyond. If that sounds like an organization you want to be a part of, we would love to have you.

ROLE OVERVIEW and PURPOSE

The Registered Nurse of Utilization Management will streamline communication between the PACE provider network, Medical Director, Interdisciplinary Team, and the Finance Team. This role will ensure efficient service authorizations and documentation of appropriate and high-quality services are aligned with the participants' needs and goals of care. Additionally, this role will manage and oversee communication processes and decision-making regarding participant service review and authorization, ensuring consistent and accurate documentation throughout the care cycle that supports appropriate payment of service claims.

RESPONSIBILITIES

• Enforces PACE program service authorization policies, ensuring that participant care and related claims are reasonable/necessary for diagnosis or treatment and consistent with primary care provider (PCP) coordination decisions

• Monitors participate care and related claims are in accordance with accepted medical standards and consistent with the participant care needs, including level of care and advanced care planning principles

• Participates in various aspects of the utilization management process, including:

• Concurrent reviews of hospital admissions with the Interdisciplinary Team driving efficient and timely transitions of care, retrospective review of inpatient admissions under 48 hours, and claims submitted inconsistent with the service authorization

• Concurrent reviews of subacute and SNF admissions with the Interdisciplinary Team driving efficient and timely discharge plans and transitions of care

• Coordination and reviews of other services delivered by contracted providers assuring consistency with Interdisciplinary Team service authorization, care plans, and PCP coordination decisions

• Leads the provider appeal process for rejected claims, including comprehensive review of provider network appeals and collaboration with the PACE Medical Director to review and respond to appeal requests, ensuring issuance of a written determination consistent with program policies

EDUCATION/EXPERIENCE

• Bachelor's degree in nursing required

• Valid CA Registered Nurse License required

• Valid BLS certification from approved American Health Association provider required upon hire

• Four years' registered nurse experience required

• Two years utilization management experience preferred

• Experience working in risk-based integrated models of care preferred

ADDITIONAL QUALIFICATIONS (Knowledge, Skills and Abilities)

• Excellent verbal and written communication skills, including superior composition, typing and proofreading skills

• Ability to interpret a variety of instructions in written, oral, diagram, or schedule form

• Ability to use data to drive decisions and collaboration with internal and external stakeholders

• Excellent strategic thinking, problem solving, and decision-making skills

• Ability to apply leadership skills to motivate and guide teams toward timely and efficient care management strategies

• Ability to successfully manage multiple tasks simultaneously

• Excellent planning and organizational ability

• Ability to work as part of a team as well as independently

• Ability to work with highly confidential information in a professional and ethical manner

Physical Requirements

• Ability to lift/carry 10 lbs/weight

• Ability to stand for long periods of time

Neighborhood Healthcare offers a generous benefit plan that includes: Partially company paid Medical, Dental, and Vision Plans. Two plus weeks of vacation, Nine Holidays including two Floating Holidays of your choosing, Sick/Personal time, Volunteer Time Off (VTO), 403b Retirement plan (similar to a 401k), optional Health and Wellness events, and much more!

Pay range: $51.50 - $62.75 per hour, depending on experience.