Registered Nurse - Utilization and Care Transitions

Neighborhood Healthcare•Riverside, CA

6d•$50 - $75•Onsite

About The Position

Neighborhood Healthcare PACE is a managed medical plan built around surrounding participants with a team of physicians, nurses, social workers, therapists and care coordinators to help them maintain good health and a good quality of life. Our goal is to keep our seniors happy and healthy at home surrounded by their family and community. As a private, non-profit 501(C) (3) community health organization, we serve over 500k medical, dental, and behavioral health visits from more than 100,000 people annually. With two PACE centers located in Riverside County, our PACE program is positioned to serve over 650 senior participants. The Utilization Management (UM) and Transitional Care Nurse Navigator/Liaison is responsible for building strong relationships with local hospitals, skilled nursing facilities (SNFs), and other care providers to ensure smooth transitions of care for PACE participants. The role focuses on improving care coordination, fostering collaboration, and ensuring compliance with federal and state regulations while enhancing the participant’s experience. Schedule: Monday-Friday, 8am-5pm. This position is onsite.

Requirements

Bachelor’s degree in nursing required
Valid CA Registered Nurse License required. Registered Nurse (RN) with an active, unrestricted license to practice in the state.
Minimum of 3 years of clinical nursing experience required, with at least 1 year in transitional care, case management, or utilization review.
Current Basic Life Support (BLS) certification through an American Heart Association (AHA) approved source is required upon hire and must be maintained as a condition of employment.
Valid CA driver's license and proof of auto insurance required

Nice To Haves

Experience in PACE, SNFs, or hospital settings is preferred
AHA-approved courses include an in-person, hands-on skills check with a certified instructor using a mannequin to demonstrate CPR and emergency response techniques.
Online-only BLS courses without a live skills check do not meet this requirement.
Experience working in risk-based integrated models of care preferred
Certification in Case Management (CCM) or equivalent preferred
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

Responsibilities

Act as the primary point of contact for transitions between hospitals, SNFs, and home care settings.
Ensure timely and effective communication among all stakeholders, including physicians, discharge planners, and PACE interdisciplinary teams (IDTs).
Monitor participant transitions to ensure compliance with regulatory requirements, including the timeliness of physician visits and follow-ups.
Follow up on participant hospitalizations to ensure proper transitions to SNFs or home, ensuring compliance with new and existing regulations.
Develop and maintain strong relationships with Directors of Nursing, Case Managers, and other key staff at local hospitals and SNFs.
Serve as a liaison to build trust and streamline communication between PACE and external providers.
Conduct weekly visits to contracted facilities to maintain a physical presence and reinforce relationships.
Address any care-related concerns promptly and ensure participants receive quality care aligned with their care plans.
Ensure all transitions of care meet the requirements outlined in federal regulations, including 42 CFR §483.30.
Maintain accurate documentation of participant care and transitions in compliance with regulatory and organizational standards.
Participate in IDT meetings to update the team on participant transitions and facility interactions.
Collaborate with medical directors and providers to align care plans and ensure consistency of orders, medications, and treatments.
Obtain and maintain access to facility electronic medical records (EMRs) to monitor participant care effectively.
Document relevant participant data to support care coordination and oversight.
Oversee and ensure the timely completion of all required physician visits, including initial visits and routine follow-ups.
Ensure orders for medications and treatments are in place and meet participant needs during transitions of care.
Serve as an advocate for PACE participants to ensure they receive appropriate care during transitions.
Educate participants and their families on care plans and post-discharge instructions.
The Nurse Navigator/Liaison will support up to 325 PACE participants to ensure effective care coordination and compliance.
Perform other duties as assigned in support of departmental and organizational goals