UM Transition of Care (TOC) Nurse- Bakersfield 1.1

Utilization Management Transitions Of Care Nurse

Location: Bakersfield, CA. (Onsite)

Classification: Full-Time

This position is non-exempt and will be paid on an hourly basis.

Universal Healthcare MSO's standard operating hours are Monday through Friday, from 8:00 a.m. to 5:00 p.m. Pacific Time. Unless otherwise specified, all employees are expected to work their assigned schedules and remain available during these operational hours.

To support business operations and after-hours member needs, employees within the Utilization Management (UM) department may be assigned schedules that differ from standard business hours. Candidates accepting a position within the department should be aware that work schedules may be adjusted based on operational requirements. Currently, the anticipated alternate schedule for this role is 9:00 a.m. to 6:00 p.m.

Benefits:

Medical

Dental

Vision

Paid Time Off (PTO)

Floating Holiday

Simple IRA Plan with a 3% Employer Contribution

Employer Paid Life Insurance

Employee Assistance Program

Compensation: The initial pay range for this position upon commencement of employment is projected to fall between $31.00- $38.74 for CA Licensed LVN and $43.35-54.18 for CA Licensed RN. However, the offered base pay may be subject to adjustments based on various individualized factors, such as the candidate's relevant knowledge, skills, and experience. We believe that exceptional talent deserves exceptional rewards. As a committed and forward-thinking organization, we offer competitive compensation packages designed to attract and retain top candidates like you.

Position Summary: The Utilization Management Transitions Of Care (TOC) Nurse supports the Utilization Management (UM) department by conducting hospital bedside visits, engaging with members during inpatient stays, and facilitating timely, coordinated transitions from inpatient care to outpatient follow-up. This position requires regular travel to designated hospitals to visit hospitalized members in person. The TOC Nurse collaborates with hospital case managers, discharge planners, physicians, nursing staff, members, caregivers, primary care providers, and internal UM and care-management teams to identify potential clinical, functional, psychosocial, and logistical barriers that may affect discharge planning and continuity of care. The TOC Nurse gathers relevant clinical and demographic information, reviews available discharge plans and follow-up needs, communicates identified concerns to appropriate clinical personnel, and assists with coordinating post-discharge appointments and services. The nurse supports timely documentation and follow-up in accordance with established UM workflow, organizational policies, and applicable requirements.

The position serves as a liaison between the hospital and the IPA's Utilization Management and Care Coordination teams, helping bridge communication and workflows to support continuity of care. The TOC Nurse also assists with designated quality-measure activities by supporting follow-up, documentation, identification of care gaps, and coordination with members and providers as assigned. The RN or LVN performs duties only within the individual's licensure, education, training, and authorized scope of practice. Medical necessity determinations and authorization decisions are handled by appropriately authorized personnel under established policies and procedures.

Essential Duties And Responsibilities:

Hospital Visits And Bedside Member Engagement

Travel to designated hospitals and conduct in-person bedside visits with assigned hospitalized members.

Coordinate visits with hospital personnel in accordance with facility access, privacy, and infection-control requirements.

Establish rapport with members and their families or caregivers using professional, compassionate, and culturally appropriate communication.

Verify member demographics, contact information, primary care provider, specialists, caregiver information, pharmacy, and other pertinent information.

Gather relevant information regarding the hospitalization, anticipated discharge plan, follow-up needs, and existing outpatient appointments.

Identify potential barriers to a successful transition of care, including functional limitations, social needs, caregiver availability, transportation, medication access, and access to follow-up services.

Communicate clinical concerns, changes in member status, and unresolved barriers to the appropriate licensed clinical personnel or treating team.

Collaborate with hospital case managers, discharge planners, nursing staff, social workers, and other members of the interdisciplinary team.

Respect member rights, preferences, confidentiality, and the member's right to decline a bedside visit.

Discharge Planning And Clinical Coordination

Gather relevant clinical and discharge-related information to support UM and transitions-of-care workflows.

Review available discharge instructions, medication information, recommended follow-up, and post-discharge service needs within the individual's licensure and scope of practice.

Identify potential gaps in discharge planning, continuity of care, or access to recommended services.

Communicate clinical concerns, discrepancies, and potential risks to the appropriate clinical personnel.

Coordinate with hospital personnel to obtain discharge information and supporting documentation through established processes.

Monitor anticipated discharge dates and communicate changes to the appropriate UM personnel.

Support referrals to care management or other appropriate resources when additional assistance may be needed.

Escalate urgent clinical concerns to appropriate treating or emergency response personnel in accordance with facility procedures and organizational protocols.

Support discharge planning without independently directing treatment or making decisions outside the individual's authorized scope.

Transitions Of Care And Outpatient Appointment Coordination

Assist members with scheduling, confirming, and rescheduling primary care and specialty appointments following hospitalization.

Coordinate follow-up appointments based on discharge instructions, provider recommendations, and established organizational workflows.

Verify appointment dates, times, locations, provider information, and other relevant details.

Communicate follow-up plans to members and caregivers in an understandable and culturally appropriate manner.

Identify barriers to attending follow-up appointments, including transportation, scheduling, mobility, communication, and access to care.

Communicate unresolved barriers to the appropriate UM or care-management personnel for further intervention.

Assist with coordination of post-discharge services and referrals as assigned.

Conduct post-discharge follow-up activities when indicated by established workflows or directed by UM leadership.

Document appointment coordination, member outreach, identified barriers, interventions, and outcomes.

Utilization Management And Care Coordination Support

Gather accurate member-specific information needed for timely and effective coordination of care.

Communicate relevant clinical and nonclinical information to authorized UM personnel.

Assist with identifying members who may benefit from additional clinical review, care management, or other appropriate services.

Coordinate with UM nurses, physicians, hospital personnel, and other interdisciplinary team members to support continuity of care.

Follow established UM policies, procedures, workflows, documentation standards, and escalation protocols.

Ensure medical necessity determinations and authorization decisions are performed only by appropriately authorized personnel.

Participate in UM initiatives and process-improvement activities related to discharge planning, transitions of care, and member experience.

Care Coordination Team Collaboration And Quality Measures

Serve as a communication link between Utilization Management and the Care Coordination team to support timely referrals, handoffs, and continuity of care.

Identify members who may benefit from Care Coordination outreach based on hospitalization, discharge needs, identified barriers, or established referral criteria, and route referrals according to workflow.

Share relevant discharge plans, follow-up needs, and barriers with authorized Care Coordination staff using approved communication and documentation processes.

Follow up on assigned handoffs to help ensure referrals and next steps are communicated and documented.

Assist with designated quality-measure activities, such as identifying potential gaps in care, supporting member outreach, helping coordinate recommended follow-up, and documenting outcomes as assigned.

Collaborate with UM, Care Coordination, Quality Improvement, providers, and other appropriate teams on initiatives intended to improve continuity of care and close identified care gaps.

Maintain accurate, timely documentation of referrals, handoffs, member outreach, follow-up, and quality-related activities.

Escalate unresolved barriers or concerns that may affect continuity of care or completion of quality-related follow-up to the appropriate team.

Documentation And Information Management

Accurately and timely document bedside visits, member interactions, information obtained, discharge-related findings, identified barriers, interventions, and follow-up activities.

Enter documentation into the designated electronic medical record, UM platform, or other approved system.

Communicate pertinent findings and outstanding needs to the appropriate UM or clinical personnel