Lead Concurrent Review/Transition of Care Nurse, RN - 25-198

We’re delighted you’re considering joining us!

At Hill Physicians Medical Group, we’re shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.

Join Our Team!

Hill Physicians has much to offer prospective employees.  We’re regularly recognized as one of the “Best Places to Work in the Bay Area” and have been recognized as one of the “Healthiest Places to Work in the Bay Area.” When you join our team, you’re making a great choice for your professional career and your personal satisfaction.

DE&I Statement:

At PriMed, your uniqueness is valued, celebrated, encouraged, supported, and embraced. Whatever your relationship with Hill Physicians, we welcome ALL that you are.

We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it's right!

Job Description:

Manages inpatient and outpatient utilization to assure that medical care is appropriate, efficient, and medically necessary.

Job Responsibilities

• Conduct concurrent and retrospective review of inpatient and outpatient utilization according to approved criteria.
• Support proactive discharge planning, transfers, and redirection.
• Identify barriers to efficient utilization and facilitate resolution.
• Reduce avoidable bed day use by applying applicable criteria and properly documenting decision.
• Proactively and collaboratively interface with HMOs, physicians, and members and their families to assist in expediting appropriate discharge.
• Refer members to various other departments for follow-up (i.e., Case Management, Disease Management, TPL, COB).
• Utilize department standards for authorization turnaround time.
• Issue denial letters in accordance with policy.
• Support Medical Management Team authorizations, clinical initiatives, and other responsibilities.
• Participate in the 24-hour on-call access program.
• Perform other duties as assigned.

Required Experience

• Minimum three years' clinical nursing experience.
• Excellent organizational and communication skills and ability to meet timeframes.
• Ability to work effectively with a variety of customers including physicians, office staff, and members.
• Ability to work independently and make appropriate decisions.
• Computer skills.
• Managed-care experience and certification preferred.

Required Education

• Active, unrestricted, California Nursing License.  Registered or Licensed Vocational Nurse.

Additional Information

Salary: $110,000 - $120,000 Annual

Hill Physicians is an Equal Opportunity Employer