Nurse Care Management LPN (Virtual)

Department: Managed Services

This position will be located near the Dallas area. Must have CA RN license or be open to obtaining.

Relocations assistance is available.

We're hiring for 3 shifts, 7am, 7md, 7pm.

The Emergency Prospective Review (EPR) / Transfer Center RN has the responsibility to conduct a review of all patients requiring hospital admission from the emergency room at all facilities after stabilizing care has been initiated for medical necessity and appropriateness. Also, the EPR-RN is responsible for reviewing all interfacility transfer request from non-PIH facility in accordance to transfer policies, Health and Safety Codes, and applicable laws (COBRA/EMTALA). The EPR-RN performs, and supervises the EPRN-LVN, in utilization review with a prominent level of expertise by using approved criteria that demonstrates medical necessity to achieve appropriate authorization and reimbursement for services for the appropriate level of care and status (Inpatient, Observation, or Outpatient). EPR-RN Communicates medical necessity criteria effectively to outside insurance providers to obtain appropriate authorization for services up front or engages in disagreement of care in accordance with Health and Safety Codes. Additionally, EPR-RN collaborates closely with patients insurance and various payors to coordinate and assist with reparation/transfer of out-of-network patients from PIH facility to the patients contracted facility including coordination of post-emergency discharge needs, as necessary. EPR-RN is also responsible for the repatriation of all PHP risk patients from non-PIH facilities to any one of the PIH facilities in an expeditious manner. EPR-RN conducts emergency physician-to-emergency physician discussions of members and provides authorization for post-stabilization care of PHP members presenting at a non-PIH facility and is required to assist in making other appropriate arrangements to promote/enhance continuity of care. Similarly, EPR -RN is responsible for the issuance of post stabilization care (PSC) denial to facilities and providers who fail to meet requirements in accordance with Health and Safety Codes. Lastly, the EPR-RN Works collaboratively with House Supervisor or designee in ensuring timely bed assignment and placement of patient admissions or transfers from PIH ED or outside facility. The position serves as a liaison between patients, families, providers, payors, and PIH Health leadership to optimize resource utilization and patient outcomes. This position is considered hybrid with remote and in-office assignment.

SPECIFIC SKILLS NEEDED

Excellent verbal and written communication skills

Ability to follow chain of command

Knowledge of hospital operations especially from an ER, ICU, nursing unit, environmental

services and financial perspective.

Knowledge of EMTALA regulations

Advanced ability to multi-task and maintain focus

Proactive, can-do approach and desire to build positive working relationships through collaborative

problem-solving

Self-motivated and results oriented. Must be able to demonstrate sound decision making, flexibility

and prioritization skills.

Strong organizational skills

Basic computer skills; Outlook, Word, and Excel

EDUCATION/EXPERIENCE/TRAINING

Required:

Maintain an active California RN

Minimum of two (2) years of acute hospital nursing experience or similar field

Preferred

CCM or ACM (Certified Case Manager, Accredited Case Manager)

Minimum of one (1) year acute hospital nursing experience in Critical Care or Emergency Department

Previous experience in case management, access management or utilization management

Knowledge of payer requirements

PIba2bdb34dfcb-26289-40522414