CLINICAL PROGRAMS RN

C2Q Health Solutions•New York, NY

3d•$100,000 - $115,000•Remote

About The Position

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.

Requirements

BSN required
Minimum of three to five (3 - 5+) years’ experience in a hospital or home care clinical setting.
Knowledgeable about Medicare and Medicaid guidelines.

Nice To Haves

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.

Responsibilities

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.
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.
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.