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Remote position following training ?
The Hill Next Generation Accountable Care Organization (NG ACO) a partnership of Hill Physician's Medical Group and Evolent Health is seeking a Network Initiatives Review Nurse as a key member of the NG ACO team. The Network Initiatives Review Nurse will be an essential member of the Network Initiatives Team. The team will guide and collaborate with internal and external stakeholders to achieve network and economic outcomes. Successful implementation of Network Initiatives is critical to the success of the NG ACO.
Specific responsibilities include implementation of savings and quality initiatives, monitoring of key performance indicators, and patient record review to monitor progress towards goals ensuring optimal results.
Examples of Network Initiatives:
Post-Acute Care Initiative- partner with area Skilled Nursing Facilities (SNFs) to improve efficiency of SNF admissions for NG ACO beneficiaries. Set and monitor SNF performance around appropriate length of stay, readmission avoidance and safe and appropriate discharges. Duties may include review patient records to monitor appropriate length of stay and treatment plans. Ensure optimal collaboration between SNF discharge planners and NG ACO care management team to ensure safe discharges and avoid readmissions. Ongoing partnership meetings to monitor metrics and develop improvement plans when performance is sub-optimal. Home Health Initiative - partner with area Home Health agencies to ensure appropriate level and length of services. Set and monitor performance improvement goals where necessary. Duties may include regular rounds with home health teams to review patient progress and appropriate use of services.
What You'll Be Doing:
The Network Initiatives Review Nurse is responsible for performing concurrent and retrospective reviews, and coordination of discharge planning for SNF and home health utilization by NG ACO beneficiaries. The Nurse will act as a beneficiary advocate by expediting the care process through the continuum, working in concert with the health care delivery team to maintain high quality and cost effective care delivery.
Performs utilization review of home health services and SNF admissions
Determines medical necessity and appropriateness of services using clinical review criteria.
Accurately documents all review determinations and contacts providers and members according to established timeframes.
Appropriately identifies and refers quality issues to Medical Management or Medical Director.
Appropriately identifies potential cases for Care Management programs
Collaborates with physicians and other providers to facilitate provision of services throughout the health care continuum.
Performs accurate data entry.
Communicates appropriate information to other staff members as necessary/required.
Participates in continuing education initiatives.
Performs other duties as assigned.
Duties may include clinical and operational meeting attendance, day-to-day oversight of work streams, and reporting analysis and action development
Implement and monitor clinical network savings initiatives for the market
Ensure that the implementation plan and development of the initiatives is sufficient to address the objectives.
Collect data related to initiatives provide and present results to internal and external partners
Educate physician leaders about these recommended actions for initiatives
Drive prioritization of efforts
Meet weekly to report out on progress of network initiative with the full Hill/Evolent team and to problem solve
Maintains strong relationships with local health system partners, building credibility with hospital and physician leadership and with the provider community in the local market.
The Experience You'll Need (Required):
Licensed registered nurse or licensed vocational nurse with a current and unrestricted California license
Minimum of two years of direct clinical patient care
Minimum of one year of experience with medical management activities in a managed care environment, Medicaid managed care preferred; specifically utilization management and/or care management
Knowledge of managed care principles
Knowledge of health care resources within the community
Experience with clinical decision-making criteria sets (i.e. Milliman, InterQual)
Strong interpersonal, oral and written communication skills.
Possess basic computer skills
Hill Physicians is an Equal Opportunity Employer
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