Graduate of an accredited school of professional nursing.
Active Registered Nurse (RN) license in California.
Minimum of two years of RN experience.
At least one year of experience with frail or elderly populations.
Current CPR/BLS and First Aid certification.
Valid California driver's license.
Proficiency in electronic medical records and data entry.
Responsibilities
Proactively manage care for acutely and chronically ill participants.
Conduct reviews of various healthcare services to evaluate medical necessity.
Collaborate with case managers and providers to enhance care coordination.
Assess clinical risks and escalate issues to the appropriate teams.
Evaluate discharge plans and home care needs with the Medical Director.
Present participant updates and address discharge barriers in team meetings.
Complete assessments to evaluate transition-of-care needs.
Benefits
Monday to Friday schedule, 8 AM to 5 PM.
Opportunity to work closely with interdisciplinary teams.
Engagement in quality improvement initiatives.
Support for professional development and training.
Focus on improving clinical outcomes and participant care.
Full Job Description
Position Overview
Medix is seeking a dedicated Utilization Registered Nurse (RN) to coordinate and implement transition-of-care services for program participants. Under the supervision of the Director of Utilization Management, this role focuses on improving clinical outcomes, supporting appropriate utilization of healthcare services, and coordinating care for acutely and chronically ill participants.
The ideal candidate has strong clinical assessment and care coordination skills, experience working with older adults, and the ability to collaborate with hospitals, healthcare facilities, providers, and interdisciplinary care teams.
Key Responsibilities
Proactively manage the care of acutely and chronically ill participants to improve quality outcomes and reduce healthcare costs.
Conduct prospective, initial, concurrent, and retrospective reviews of inpatient, facility, outpatient, and home health services to evaluate medical necessity and appropriateness of care using InterQual or other approved clinical guidelines.
Collaborate with hospital case managers, facility case managers, hospitalists, and treating providers to improve care coordination and transition processes.
Assess clinical risks and quality concerns, escalating issues to the interdisciplinary team, providers, Medical Director, and Director of Quality and Compliance as appropriate.
Partner with the Medical Director and treating physicians to evaluate discharge plans, home care needs, covered services, and alternative levels of care.
Present participant status updates and address barriers to discharge and care transitions during interdisciplinary team meetings.
Complete semiannual assessments and annual reassessments to evaluate participants' transition-of-care needs, documenting all assessments and services in the electronic medical record (EMR).
Visit participants in hospitals, skilled nursing facilities (SNFs), board-and-care facilities, assisted living facilities (ALFs), and private residences as needed.
Conduct home visits to assess medical status and care needs as recommended by the interdisciplinary care team.
Coordinate transition-of-care services, including nursing, physical therapy, occupational therapy, speech therapy, and home care.
Complete and submit Level of Care Assessment Tools (LOCATs) for participants residing in contracted facilities.
Collaborate with the Director of Quality and Compliance to oversee transition-of-care quality assurance activities.
Assist with documenting and resolving participant grievances, appeals, rights violations, and other concerns related to services and quality of care.
Participate in quality improvement initiatives and maintain compliance with organizational policies and participant rights requirements.
Required Qualifications
Graduate of an accredited school of professional nursing.
Active Registered Nurse (RN) license through the California Board of Registered Nursing.
At least two years of RN experience.
At least one year of experience working with frail or elderly populations.
Current CPR/BLS and First Aid training, as required.
Valid California driver's license.
Ability to complete required TB screening and a health examination.
Knowledge of medical terminology and regulations related to long-term care.
Proficiency with computers, data entry, and electronic medical records.
Strong clinical assessment, organization, communication, and problem-solving skills.
Ability to make independent clinical decisions when appropriate and work effectively as part of an interdisciplinary team.
Ability to communicate professionally with participants, families, providers, and healthcare facility staff.
Preferred Qualifications
Experience in home health, community health, care coordination, or transition-of-care nursing.
Experience working with older adults or individuals with complex medical needs.
Familiarity with utilization review and medical necessity criteria, including InterQual.
Additional Requirements
Ability to conduct visits at healthcare facilities and participants' residences as needed.
Ability to manage competing priorities and adapt to changing participant needs.
Commitment to participant dignity, confidentiality, independence, and quality of care.
Ability to meet the physical requirements of the position, including moving throughout the workday and lifting or carrying up to 25 pounds, with or without reasonable assistance or mechanical devices.
