Job Description

This is a short-term assignment.

What you can expect!

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

Under the direction of the Integrated Transition Care Department Leadership, the incumbent will work with Hospitals and Independent Physician Association (IPA) with their assigned Team Center, that may include an LCSW, CHW, Pharmacist, Pharmacy Technician, Coordinator, Care Transition, and Transportation to initiate coordinated and continuous cost-effective quality healthcare to ensure the continuity of the Member’s care needs are met timely throughout the continuum of care and readmission prevention for our high-risk Members. This will be accomplished through concurrent review processes using nationally recognized criteria. The Integrated Transitional Care Nurse, RN will participate in providing transitional care services to the Members with each transition from one care setting to the next.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Additional Benefits

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

Competitive salary
Hybrid schedule
State of the art fitness center on-site
Medical Insurance with Dental and Vision
Life, short-term, and long-term disability options
Career advancement opportunities and professional development
Wellness programs that promote a healthy work-life balance
Flexible Spending Account – Health Care/Childcare
CalPERS retirement
457(b) option with a contribution match
Paid life insurance for employees
Pet care insurance

Key Responsibilities

Conduct Integrated Transition Care discharge risk assessment for high risk/ high acuity Members.

Oversee and perform concurrent and retrospective reviews for medical necessity per evidenced based criteria, appropriateness of service and level of care, either through Telephonic review, clinical documentation submitted by respective facilities and/or electronic medical records (EMR) access.

Conduct reviews to ensure Member’s treatment plan is consistent with Diagnosis(es), specifically initial review within twenty-four (24) hours to ensure Members meet specified criteria for the respective admission(s).

Work in collaboration with the coordinator to ensure timely arrangements for transitions to higher or lower level of care and assist with transfer orders as needed.

Ensure the concurrent or retrospective review process include referring cases that require clinical consultation with the medical director in a timely manner.

Ensure cases are appropriately referred to Care Management, Behavioral health, Health Education, Housing, community health.

Identify outliers and prepare documentation as well as report on potential quality of care issues as identified.

Process timely completion of denials process per policy. The RN will review variances in cases followed by an LVN for possible consultation with the Medical Director to determine approval for due to medical necessity or denial of days.

Conduct timely compliance and completion of documents per regulatory requirements.

Serve as the IEHP Liaison between hospitals, IPAs vendors, outside agencies and provider to ensure effective communication and collaboration in an effort to meet the Member's treatment plan and goals.

Oversee verification of delivery of ordered Durable Medical Equipment (DME), Health Home visits, set up hospital follow up visits with PCP, review of Medications with Member and transportation needs.

Oversee and complete Discharge planning assessment.

Perform medication reconciliation based on acuity and type of medications.

Outreach to Member post discharge to ensure Member attended follow up appointment, Health Home starts visits, possible in-home visit by RN or assigned LCSW as appropriate.

Generate additional follow up needed to assign to appropriate regional Behavioral Health & Care Management team.

Qualifications

Education & Requirements

Two (2) or more years of Utilization Management/Case Management in a health care delivery setting in Acute or Skilled nursing, with an emphasis on Concurrent Review and Utilization Management
High school diploma or GED required
- Bachelor's degree in Nursing from an accredited institution preferred
Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required

Key Qualifications

Must have a valid California Driver’s license and valid automobile insurance. Must qualify and maintain driving record to drive company vehicles based on IEHP insurance standards of no more than three (3) points
Knowledge of evidence based clinical criteria and California Children Services (CCS)
Must have analytical skills
Excellent communication, interpersonal and organizational skills
Self-starter and a team player

Start your journey towards a thriving future with IEHP and apply TODAY!

Work Model Location

This position is on a hybrid work schedule. (Monday & Friday - remote, Tuesday - Thursday onsite in Rancho Cucamonga, CA)

Position may require working onsite at an IEHP contracted provider facility location 5-days per week as a remote work location depending on business need.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

Pay Range

USD $91,249.60 - USD $120,910.40 /Yr.

About IEHP

With a mission to heal and inspire the human spirit, Inland Empire Health Plan (IEHP) is one of the top 10 largest Medicaid health plans, the largest not-for-profit Medicare-Medicaid public health plan in the country, and for the fourth year in a row, certified as A Great Place To Work®. Founded in 1996, IEHP supports more than 1.5 million Riverside and San Bernardino County residents enrolled in Medicaid or IEHP DualChoice (those with both Medi-Cal and Medicare). As of 2024, IEHP also offers Covered California plans, further ensuring health care access for even more IE residents. Today, IEHP has a robust network of quality doctors throughout our two counties and nearly 4,000 team members who are fully committed to the vision: We will not rest until our communities enjoy optimal care and vibrant health. To learn more, go to iehp.org.

Comprehensive Benefits

Competitive salary and a benefits package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.

Mission: To heal and inspire the human spirit.

Vision: We will not rest until our communities enjoy optimal care and vibrant health.

Values: We do the right thing by: Placing our Members at the center of our universe; unleashing our creativity and courage to improve health and well-being; bringing focus and accountability to our work; and never wavering in our commitment to our Members, Providers, Partners, and each other.

Winning Team Culture

Certified as A Great Place To Work® four years in a row.

Industry

Healthcare & Social Services

Company Size

1,001-5,000 employees

Headquarters

Rancho Cucamonga, CA

Year Founded

1995

Website

iehp.org

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