Organizational Description

The Community Health Center Network (CHCN), sister organization to the Alameda Health Consortium, is made up of the eight federally qualified community health centers in Alameda County. CHCN functions as the managed care MSO for our health centers, contracting with the Alameda Alliance for Health. In order to help our health centers meet their missions of providing the best possible care to their communities, we also provide a broad range of training, technical assistance, quality improvement, information technology, and data analytic services.

Position Title: Per Diem Registered Nurse (RN)

Department: Utilization Management (UM)

Reports To: Outpatient Nurse Supervisor

Classification: Non- Exempt

Status: Per Diem, Remote/Hybrid

POSITION SUMMARY

The per diem nurse works inpatient, outpatient prior authorization or with the basic case management team when needed. The per diem nurse must have a strong clinical background to conduct concurrent reviews and retro reviews of inpatient utilization and outpatient prior authorization reviews. The per diem nurse needs to have knowledge in coordination of care and able to collaborate with CHCN members, physicians, specialty providers, and multidisciplinary teams within the Primary Care Physician (PCP) clinic setting, managed Medi-Cal Health Plans, and California Children’s Services (CCS) Case Managers. This position will identify, screen, coordinate and process authorization requests covering the entire spectrum of medical services, which include, but are not limited to, making determinations of coverage and medical necessity for requested services and utilizing CHCN’s clinical criteria guidelines to manage patients with complex post-acute care needs according to the Care Transitions Model.

ESSENTIAL POSITION RESULTS

The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may perform other duties as assigned. Please see more details on the job descriptions of Inpatient Care Transitions Nurse, UM Prior Authorization Nurse, and Outpatient Basic Case Management Nurse.

A. Inpatient Care Transitions Nurse

• Manage and coordinate in-patient review and discharge planning and case management activities related to immediate post-discharge needs.
• Train in and implement Care Transitions Model in discharge planning; participate in use of the model in a clinic setting.
• Support proactive hospital discharge planning, transfers, and redirection.
• Proactively and collaboratively interface with medical director, HMOs, clinic and facility staff, outside agencies, member and their families to assist in expediting appropriate discharge and coordination of care.
• Write denial letters, and other Notices of Action, to member/providers using HMO templates.
• Serve as a liaison between hospital, clinics, health plan, vendors, outside agencies, and providers.

B. UM Prior Authorization Nurse

• Provide timely referral determination by accurate application of medical review criteria including, MCG (Milliman Care Guidelines) and identify cases for Medical Director review.
• Make appropriate member and provider “Notice of Action” language selection for all UM determinations.
• Make appropriate selection of preferred and contracted providers, when possible, within CHCN’s network.
• Works closely with supervisors/leads to address issues and delays that impact TAT compliance.
• Monitors pended documents for final determination.

C. Outpatient Basic Case Management Nurse

• Advocates for managed Medi-Cal patients and help them achieve their best health.
• Proactively and collaboratively interfaces with clinics, HMOs, physicians, internal staff, members and their families to assist in proper Care Coordination duties.
• Refers members to various other departments (such as Health Plan Complex Case Management and Case and Disease Management) for follow-up, as appropriate, with medically complex members.
• Refers members to Behavioral Health, QI, and Care Neighborhood programs inside and outside the organization.
• Builds and maintain appropriate relationships on behalf of CHCN.
• Assesses new patients, evaluate, and determine of patient’s needs and provides services and resources to patients.
• Educate patients and families about health care plans and options and provides emotional support to patients and families.
• Documents accurately in medical records.

Position Profile

• Responsible for attending internal and external meetings and trainings as requested.
• Work directly with the Health Plans, Providers, CCS, and Medical Directors to facilitate the delivery of quality care and services to members and CHCN clinics.
• Responsible for maintaining job performance standards as defined by CHCN.
• Responsible for excellent customer service and telephone communications with all callers, both internal and external.
• Attend all mandatory customer service and ethics training.
• Maintain and keep in total confidence, all files, documents and records that pertain to the operation of business.
• All other job-related duties as it relates to the job function or as delegated by the management team.

SUPERVISORY RESPONSIBILITIES

None

MINIMUM QUALIFICATIONS

• Active, unrestricted, California Registered Nurse (RN) License
• Minimum 3-4 years of UM experience preferred and ability to learn new roles/tasks within the organization. Preferred CM experience in a hospital, Outpatient, or insurance setting such as HMO/PPO, managed care or MSO with ability to learn new workflows as needed.
• Minimum of 3-4 years of hospital experience in inpatient medical, surgical, intensive care, and/or psychiatric units
• Excellent communication, organizational and time management skills with the ability to meet tight timeframes and turn-around times. Ability to work independently in most instances, requiring limited supervision
• Sound decision-making skills including problem solving, critical thinking, and good clinical judgment for clinical and non-clinical issues
• Strong understanding of the Managed Care environment and the MSO partnership
• Ability to meet member’s challenging needs with extensive collaboration with the Health Plan partners
• Computer skills: Ability to use EZ-CAP (preferred) and Microsoft Outlook, Word and Excel required
• Experience in varied health care delivery settings desirable
• Self-motivated and self-managed person with the desire to learn and the ability to work well with others as a team
• Ability to prioritize and manage multiple projects and maintain deadlines at all levels
• Knowledge and application of English grammar including composition, editing and proofreading skills
• Ability to display a courteous, patient, and helpful attitude toward co-workers at CHCN organization
• Analytical and problem resolution skills
• Understanding of community health centers and safety net providers
• Must foster a “Can-Do” attitude

CERTIFICATES AND/OR LICENSES

Current and Unrestricted RN License

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit and use hands to finger, handle, or feel. The employee is frequently required to talk or hear. The employee is frequently required to stand; walk; reach with hands and arms and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus.

WORKING CONDITIONS AND ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly exposed to an inside environment.

The Community Health Center Network is an Equal Opportunity Employer.