Clinical Reviewer

Base Pay $75,920.00 - $99,058.00 / Year Job Category Clinical Reviewer, Registered Nurse, Case Management Industry Incarcerated Patients, Enhanced Case Management, Care Coordination Employee Type FT Non-Exempt Required Degree 4 Year Degree Travel 5% Manage Others No Description Minimum Qualifications Education Graduate of an accredited Registered Nursing Program required. Bachelor's degree in Nursing, Public Health, or related field preferred. Licensure Current California Registered Nurse license required. Current Basic Life Support (BLS) certification required. Valid California Driver's License and proof of automobile insurance may be required depending on organizational needs. Experience Required Minimum two (2) years of clinical experience in: Primary care, Ambulatory care, Community health, Case management, Care coordination, Population health Preferred Federally Qualified Health Centers (FQHCs). High-risk and medically complex populations. Behavioral health and substance use treatment coordination. Case Management Documents and Audits Population Health registries and outreach Knowledge of Knowledge of nursing principles and practices. Enhanced Care Management (ECM) Comprehensive Assessments and Care Plans. Understanding of Managed Care Plan (MCP) requirements and regulatory standards. Care coordination principles across primary care, specialty care, behavioral health, substance use services, and community-based services. Understanding of chronic disease management, preventive care, mental health, sexual health, and substance misuse prevention. Medication administration, medication reconciliation, and patient monitoring practices. Understanding of population health management, patient registries, and care gap closure strategies. Social determinants of health and social risk screening processes. Familiarity with quality improvement methodologies, performance improvement initiatives, and grant-related activities. Working knowledge of the California Nurse Practice Act and applicable healthcare regulations. Ability to: Collaborate effectively with interdisciplinary care teams. Communicate effective with patients and community partners Identify care plan gaps, barriers to care, and appropriate interventions. Manage an assigned caseload efficiently while prioritizing multiple responsibilities. Provide compassionate, affirming, and culturally responsive care to diverse populations. Adapt to changing patient, provider, and organizational needs. Analyze clinical information and make sound decisions within scope of practice. Conduct outreach and engage patients in preventive and ongoing care. Support quality improvement, compliance, and performance improvement initiatives. Work independently while maintaining effective communication with providers and care teams. Review, audit, and evaluate care plans for completeness, accuracy, and compliance. Administer medications, injections, vaccines, and perform basic laboratory testing. Educate patients, families, case managers, and staff. Develop workflows, policies, procedures, and educational materials. Skills: Strong care coordination and case management skills. Effective patient assessment, monitoring, and documentation skills. Strong verbal and written communication skills. Strong problem-solving and troubleshooting skills. Excellent organizational and time-management skills. Proficiency in maintaining accurate medical records and care management documentation. Essential Functions The essential functions listed are representative of the position. Reasonable accommodation may be made to enable qualified individuals with disabilities to perform these functions. ( Duties may include, but are not limited to, the following): Clinical Care Coordination & Case Management Troubleshoot issues and provide guidance, coaching, and educational support to case managers. Work closely with interdisciplinary care team members across primary care, specialty care, behavioral health, substance use services, care coordination, and community health to support optimal patient outcomes across the continuum of care. Under MD/DO oversight, and in consultation with the interdisciplinary care team, ensure safe and effective coordination of care within and between care settings. Monitor patient conditions, implement care plan interventions, and report changes to the medical team. Coordinate and review cases, including referrals, laboratory results, diagnostic tests, appointments, and other key services. Manage an assigned caseload efficiently and effectively using strong time-management skills. Adapt to changing patient, provider, and organizational needs to ensure continuity of care. ECM Assessment & Care Plan Oversight Assist the ECM Clinical Consultant in auditing ECM Comprehensive Assessments and Care Plans to ensure compliance with best medical practices and Managed Care Plan (MCP) requirements. Review care plans for completeness, identify and address gaps or barriers to care, and collaborate with case managers to finalize care plans prior to approval and sign-off. Supports the Community Health Justice Involved initiative by utilizing an RN license to provide daily clinical oversight and complete billing upon review of Health Risk Assessments and Re-Entry Care Plans. Attends regular ECM MDT meetings with members of the interdisciplinary healthcare team, leveraging RN licensure and clinical expertise to provide recommendations and finalize care plans, ensuring accurate documentation and timely billing. Medication & Health Monitoring Perform medication reconciliation by documenting current medications, comparing them with provider orders, and resolving discrepancies with the medical team. Monitor patient registries to identify individuals due for care or those with abnormal vitals, laboratory results, or other clinical indicators, and conduct outreach to connect patients with needed services. Conduct social risk screenings to identify barriers impacting health outcomes. Develop educational resources and materials to support staff training and patient education. Provide patient education to support self-management and disease management goals. May assist in patient community events. Quality Improvement, Compliance & Program Development Develop clinical workflows, policies, and procedures. Participate in grant initiatives, quality improvement projects, and performance improvement activities. Supports Quality Team Initiatives, ER Utilization and Transitional Care Services as assigned. Additional Responsibilities Ability to adapt to change based on the needs of the patient, provider(s) and organization. Participate in grant and performance improvement projects and processes. Other duties as assigned. Travel Requirements Occasionally may travel to other sites to attend meetings or training; occasionally overnight for training. Tools & Technology Tools: Intravenous needles, bags and tubing; nebulizers or accessories; spirometers or its accessories; oxygen equipment or accessories, autoclave, glucometer, UA machine, sphygmomanometers, calculators or accessories, photocopiers, scanners, faxing equipment, computers and keyboards, telephones, EMR and other HIT systems. Technology: Patient charting and scheduling software (NextGen); Microsoft Office programs including Word, Excel, Outlook, PowerPoint and Visio; population health analytic software. Knowledge Medicine, customer and personal services, English language, mathematics, education and training, patient safety and security, infection control, HIPAA, MSDS, medical terminology, personal protective equipment. Abilities Oral comprehension, oral expression, written comprehension, written expression, problem sensitivity, deductive reasoning; inductive reasoning, multi-task and shift priorities, make sound independent decisions by applying policies and procedures and using available resources. Work Activities Communicating with supervisors, peers, or subordinates; getting information; interacting with computers; performing administrative activities; making decisions and solving problems; organizing, planning, and prioritizing work; communicating with people outside organization; establishing and maintaining interpersonal relationships; documenting/recording information. Work Styles Integrity; dependability; attention to detail; cooperation; independence; initiative; self-control; adaptability/flexibility; concern for others; stress tolerance. Work Context Physical Demands: The physical demands and work environment described here are representative of those that must be met by an employee to successfully perform the essential function of the job, with or without accommodation. Prospective employees must complete a pre-employment medical exam (Occupational Group IV) which will measure the ability to: See well enough to read fine print and view a computer screen; speak and hear well enough to understand, respond, and communicate clearly in person and on the telephone; independent body mobility sufficient to stand, sit, walk, lift or move, stoop, and bend to access the work environment and a standard office environment; manual dexterity and sufficient use of hands, arms and shoulders to repetitively operate a keyboard and to write; and the ability to sit or walk for prolonged periods of time. Occasionally may be required to lift/move or assist in lifting/moving up to 50lbs. Reasonable accommodation may be made for some of these physical demands for otherwise qualified individuals who require and request such accommodation. Work Environment: Generally, a typical office environment. #J-18808-Ljbffr Jimmy Jazz