Post Acute Clinical Review RN

Central Health • Austin, TX

2d

About The Position

Overview The Post Acute Clinical Review Registered Nurse (RN) is responsible for clinically reviewing, managing and coordinating referrals to post-acute care, ensuring completeness and accuracy to support medical necessity. This role ensures timely access for admission to the Skilled Nursing Facilities (SNF) or appropriate healthcare facilities and/or services. The RN utilizes clinical knowledge, experience, and assessment of clinical documentation for medical necessity review. The RN serves as a key clinical liaison among providers, patients, SNF partners and internal stakeholders to support safe transitions to post acute services and continuity of care. Responsibilities JOB FUNCTIONS: Essential Functions: Conduct clinical review of incoming post-acute care referrals to ensure completeness and accuracy of documentation to support medical necessity for short term SNF placement or other post-acute care services. Thorough review of eligibility to ensure active enrollment in health coverage. Determine whether referrals meet established clinical and programmatic criteria with loop closure communication for referrals that do not meet criteria to referral source. Manage referral workflows to support timely decision making, prioritization, and throughout. Provide clear status updates to internal teams, providers, and external partners. Identify clinically complex, high-risk, or unclear cases and escalate to internal providers for further review and determination. Utilize nursing knowledge and clinical judgment to assess referral urgency and complexity to prioritize accordingly for timely placement. Conduct a thorough review of inpatient hospital records to verify clinical documentation meets medical necessity criteria for post-acute placement. Collaborate with inpatient care teams, case management, and providers to clarify referral needs and/or clinical documentation. Serve as the initial RN to review referral escalations to providers to support clinical analysis and determining appropriateness for SNF placement. Serve as a clinical liaison between providers, hospital case management teams, post-acute care facilities and other external partners. Monitor and track referral progress and proactively follow up to ensure seamless continuity of patient care and avoid unnecessary delays. Identify, assess and address barriers to referral progression including but not limited to patients’ SNF location preferences, SNF admission guidelines, medical power of attorney (MPOA) considerations, and discharge medications. Communicates with Skilled Nursing Facility liaison and admissions teams to facilitate clinical acceptance, bed placement and coordination of patient arrival. Collaborates with Utilization Management department to optimize resource allocation. Serve as primary liaison with durable medical equipment (DME) vendors ensuring required equipment is delivered prior to patients’ arrival at the skilled nursing facility. Attends staff meetings, huddles, and education offerings (in person and virtual) to maintain role competency and department alignment. Supports organizational and departmental initiatives to promote and maintain a collaborative and positive workplace culture. Maintain accurate, timely, and appropriate documentation of referral reviews, determinations, and care coordination activities in the electronic health record system. Adhere to HIPAA compliance, organizational policies and regulatory standards. Awareness of department performance indicators, metrics, and quality measures. Performs other duties as assigned. Knowledge, Skills and Abilities: Knowledge and proficiency in the practice of nursing and documentation requirements. Knowledge of post-acute care settings and services including skilled nursing facilities and other postacute care settings. Knowledge of medical necessity and utilization review concepts and documentation standards. Ability to work with medical and nursing staff to establish and maintain clinical and operational standards of practice. Ability to work in a highly collaborative manner with patients and other internal or external service providers. Knowledge of electronic health record systems and clinical documentation workflows. Ability to deliver high‑quality customer service through telephone, electronic, and in‑person communication. Strong problem‑solving skills to identify and address barriers to better serve patients and staff Proficiency in applying Microsoft Office software tools in a system environment. Strong attention to detail and accuracy. Strong assessment, critical thinking and effective decision-making skills. Knowledge of complex medical conditions and co morbidities. Ability to apply independent nursing judgment in reviewing referrals, assessing medical necessity, and determining appropriateness. Ability to thrive in a complex and dynamic work environment with multidisciplinary, cross-functional teams and matrixed team structures. Knowledge of social determinants of health issues and demonstrate cultural humility and sensitivity when work with underserved patient populations. Skill in triaging and ensuring appropriate level of care for patients. Ability to maintain professionalism, confidentiality, and ethical standards in all interactions.

Requirements

• Associates Degree (higher degree accepted)
• Graduation from an accredited school of nursing with an Associate Degree in Nursing (ADN) -Required
• Minimum of 2 years of clinical nursing experience (preferably acute care, ambulatory or case management) -Required
• Registerd Nurse (RN) - State Licensure and/or Compact State License
• Current unrestricted RN license to practice nursing in the State of Texas - Upon Hire Required
• BLS - Basic Life Support Basic Life Support (BLS) - Obtained through approved American Heart Association Training Network or American Red Cross - Upon Hire Required
• Driver's License - Valid Driver's License -Upon Hire Required
• Knowledge and proficiency in the practice of nursing and documentation requirements.
• Knowledge of post-acute care settings and services including skilled nursing facilities and other postacute care settings.
• Knowledge of medical necessity and utilization review concepts and documentation standards.
• Ability to work with medical and nursing staff to establish and maintain clinical and operational standards of practice.
• Ability to work in a highly collaborative manner with patients and other internal or external service providers.
• Knowledge of electronic health record systems and clinical documentation workflows.
• Ability to deliver high‑quality customer service through telephone, electronic, and in‑person communication.
• Strong problem‑solving skills to identify and address barriers to better serve patients and staff
• Proficiency in applying Microsoft Office software tools in a system environment.
• Strong attention to detail and accuracy.
• Strong assessment, critical thinking and effective decision-making skills.
• Knowledge of complex medical conditions and co morbidities.
• Ability to apply independent nursing judgment in reviewing referrals, assessing medical necessity, and determining appropriateness.
• Ability to thrive in a complex and dynamic work environment with multidisciplinary, cross-functional teams and matrixed team structures.
• Knowledge of social determinants of health issues and demonstrate cultural humility and sensitivity when work with underserved patient populations.
• Skill in triaging and ensuring appropriate level of care for patients.
• Ability to maintain professionalism, confidentiality, and ethical standards in all interactions.

Responsibilities

• Conduct clinical review of incoming post-acute care referrals to ensure completeness and accuracy of documentation to support medical necessity for short term SNF placement or other post-acute care services.
• Thorough review of eligibility to ensure active enrollment in health coverage.
• Determine whether referrals meet established clinical and programmatic criteria with loop closure communication for referrals that do not meet criteria to referral source.
• Manage referral workflows to support timely decision making, prioritization, and throughout.
• Provide clear status updates to internal teams, providers, and external partners.
• Identify clinically complex, high-risk, or unclear cases and escalate to internal providers for further review and determination.
• Utilize nursing knowledge and clinical judgment to assess referral urgency and complexity to prioritize accordingly for timely placement.
• Conduct a thorough review of inpatient hospital records to verify clinical documentation meets medical necessity criteria for post-acute placement.
• Collaborate with inpatient care teams, case management, and providers to clarify referral needs and/or clinical documentation.
• Serve as the initial RN to review referral escalations to providers to support clinical analysis and determining appropriateness for SNF placement.
• Serve as a clinical liaison between providers, hospital case management teams, post-acute care facilities and other external partners.
• Monitor and track referral progress and proactively follow up to ensure seamless continuity of patient care and avoid unnecessary delays.
• Identify, assess and address barriers to referral progression including but not limited to patients’ SNF location preferences, SNF admission guidelines, medical power of attorney (MPOA) considerations, and discharge medications.
• Communicates with Skilled Nursing Facility liaison and admissions teams to facilitate clinical acceptance, bed placement and coordination of patient arrival.
• Collaborates with Utilization Management department to optimize resource allocation.
• Serve as primary liaison with durable medical equipment (DME) vendors ensuring required equipment is delivered prior to patients’ arrival at the skilled nursing facility.
• Attends staff meetings, huddles, and education offerings (in person and virtual) to maintain role competency and department alignment.
• Supports organizational and departmental initiatives to promote and maintain a collaborative and positive workplace culture.
• Maintain accurate, timely, and appropriate documentation of referral reviews, determinations, and care coordination activities in the electronic health record system.
• Adhere to HIPAA compliance, organizational policies and regulatory standards.
• Awareness of department performance indicators, metrics, and quality measures.
• Performs other duties as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 251-500 employees