Long Term Supportive Services Nurse / Job Req 788830806 (Project Management)

PRINCIPAL RESPONSIBILITIES:
Under general direction of the Director, Long Term Services and Supports (LTSS) and working in cooperation with other departments, such as Utilization Management and Case management; the LTSS Nurse is responsible for evaluating the clinical information submitted to perform clinical reviews for requests for Long Term Care (LTC) and Community Supports (CS) requests as needed. This role utilizes the applicable clinical practice standards/guidelines to determine medical necessity for the service being requested.
LTC: Providing health plan clinical support to Members on the admissions and continued stay services in LTC Skilled Nursing Facilities, Intermediate Care Facilities, Subacute Facilities, both Freestanding and Distinct Part. The position provides clinical judgment and critical thinking skills to determine the appropriateness of LTC admissions and extension requests. The position will collaborate with the LTC facilities to ensure appropriate physical and behavioral healthcare and social services are provided timely and efficiently for the Alliance members. Utilizes assessments, member-centered care planning, direct provider
coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization available to Members. The LTSS Nurse will possess knowledge of current upcoming programs and services that intersect with LTC services, Enhanced Case Management, Community Support, Population Health Management, Regional Services, HCBS (Home and Community Based Services).
The position will be responsible for supporting collaboration with Skilled Nursing Facilities (SNF) and Provider Medical Groups (PMG) to facilitate and coordination authorization of services under the responsibility of the delegated PMG. The position will coordinate the identification, documentation, and resolution of LTC facility related issues in a timely manner.
CS: The LTSS Nurse processes clinical, psychosocial and social determinants of health information to ensure that members receive the most appropriate service. The position provides expert guidance to community providers, community-based organizations, hospital staff, and other internal and external partners on appropriate resources available to members to achieve optimal functioning, stability and autonomy. The goal of Community Supports services is to offer services or settings in place of services or settings covered under Medi-Cal and that are medically appropriate, cost-effective alternative to a Medi-Cal Covered service.
ESSENTIAL FUNCTIONS OF THE JOB
Performs clinical review of:Long term Care requests in:Skilled Nursing Facilities (NF-A/B), Distinct Part HospitalsIntermediate Care Facilities (ICF)Subacute Facilities
Community Supports Requests
Review of prospective, inpatient or retrospective medical records of services for medical necessity
Consultation with the Alliance Medical Director to validate patient acuity and plan of care as needed; Use clinical judgment to assess and refer members to the Case and Disease Management Department and the Enhanced Care Management (ECM) team, Community Supports, and HCBS as necessary.
Provides direction to non-clinicians who assist members with accessing services.Conducts additional assessments, when necessary, to monitor, evaluate and revise members' care plans to meet members' needs, with the goal of optimizing member health care across the care continuum. Assist in arranging for services required while coordinating with the health care team to eliminate duplication of services.Participates in interdisciplinary care team (ICT) meetings as needed for LTC members.Establishes relationships with referral sources and community resources, such as external providers, SNFs, CBAS Centers, PMGs, Community Support Providers, and care coordinators, while maintaining strict member confidentiality and complying with all Health Insurance Portability and Accountability Act (HIPAA) requirements.Facilitates care coordination with internal and external entities to improve member's short- and long-term goals in collaboration with member, caregivers, family, support systems, and physicians.Documents accurately and comprehensively based on the standards of practice and current organization policies.Performs other duties as assigned. Communicating effectively, both verbally and in writing.Comply with the organizations Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
PHYSICAL REQUIREMENTS
Constant and close visual work at desk or computer. Constant sitting and working at desk. Extensive data entry using keyboard and/or mouse. Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person. Frequent lifting of folders and other objects weighing between 0 and 30 lbs. Frequent walking and standing. Occasional travel between offices for meetings
Number of Employees Supervised: 0
MINIMUM QUALIFICATIONS:
EDUCATION OR TRAINING EQUIVALENT TO:
Bachelor of Science in Nursing or related field or equivalent experience preferred.Master of Science in Nursing or Health Administration or related field preferred.
Licenses/Certifications
Registered Nurse (RN) - Active, current, and unrestricted California License, required
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
Minimum two years of clinical experience, requiredMinimum two years of experience in managed care health plan required
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
Experience with Medi-Cal and Medicare populations and regulatory requirements.Knowledge of DMHC regulations and DHCS contractual requirements.Experience in utilization review, skilled nursing services, home health, discharge planning, behavioral health, community resources, and/or other home and community-based agenciesWorking knowledge of case/care management principlesWorking knowledge of health care contracts and benefit eligibility requirementsProficient in use of computer and supporting software in a Windows-based environment including with Microsoft Office applications and use of the internet/internet applications.Knowledge of CalAimExcellent verbal and written communication skills.Experience in skilled or long-term care facility settings.
Additional Duties
Travel to offsite locations for work.
SALARY RANGE $126,796.80 - $190,174.40 ANNUALLY
The Alliance is an equal opportunity employer and makes all employment decisions on the basis of merit and business necessity. We strive to have the best-qualified person in every job. The Alliance prohibits unlawful discrimination against any employee or applicant for employment based on race, color, religious creed, sex, gender, transgender status, age, sexual orientation, national origin, ethnicity, citizenship, ancestry, religion, marital status, familial status, status as a victim of domestic violence, assault or stalking, military service/veteran status, physical or mental disability, genetic information, medical condition, employees requesting accommodation of a disability or religious belief, political affiliation or activities, or any other status protected by federal, state, or local laws.