Concurrent Review Nurse

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🏄 California – Remote

🏄 California – Remote

💵 $96k - $140k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

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Health Plan of San Joaquin/Mountain Valley Health Plan

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1996

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

Health Plan of San Joaquin/Mountain Valley Health Plan is a regional managed care organization that provides Medi-Cal (Medicaid) and Medicare Advantage coverage—including a Dual Special Needs Plan (D-SNP)—to residents in San Joaquin County and surrounding areas. The plan offers member services, pharmacy benefits, provider networks and tools, care coordination (enhanced care management), community health programs, and compliance/quality oversight (NCQA accreditation). It focuses on serving Medicaid and dually eligible populations through partnerships with local health agencies and community initiatives.

📋 Description

• Conduct onsite and/or telephonic concurrent review of inpatient activities • Ensure member care is rendered at the most appropriate level and for the requisite length of time in compliance with HPSJ, regulatory, and contractual requirements • Confirm member care plans with providers • Identify care issues and collaborate with providers to resolve them; escalate as necessary • Make timely recommendations regarding transfers, level-of-care determinations, and discharge planning • Escalate non-standard requests to the Medical Director for review • Approve or deny services as directed • Research and resolve adjudication issues accurately and timely • Document activities in appropriate HPSJ systems according to standards • Track data as required • Compile data and produce and submit routine reports

🎯 Requirements

• Strong clinical skills as defined in California scope of practice guidelines for RNs • Ability to read, interpret, and apply complex written regulations, guidelines, and other materials • Ability to read and interpret clinical information • Strong assessment and analysis skills • Strong problem-solving skills • Basic negotiation skills • Strong oral and written communication skills • Ability to communicate professionally with diverse individuals and explain complex information • Ability to work independently and as part of a team • Time management and organizational skills • Strong customer service skills • Basic skills in Word and Excel • Ability to enter data into and navigate through multiple databases • Ability to speak and be understood in English • May require proficiency in one of HPSJ’s threshold languages • Ability to handle confidential information with appropriate discretion • In-depth knowledge of the principles and practices of concurrent review required within six months of hire • In-depth knowledge of government-sponsored programs and regulations as they apply to concurrent review required within six months of hire • In-depth knowledge of managed care principles, practices, and regulations as they apply to concurrent review required within six months of hire • In-depth knowledge of healthcare delivery systems as they apply to concurrent review required within six months of hire • Graduation from an accredited nursing school • At least three years of clinical experience as an RN in a hospital or clinic • Unrestricted California Registered Nurse license • Valid California driver license and reliable transportation, or ability to obtain transportation on demand in counties served by HPSJ if prohibited from getting a driver license due to a medically documented disability • Legal and valid work authorization, Green Card, or U.S. citizenship • Preferred: experience in case management, utilization management, or discharge planning • Preferred: experience as a clinician in a managed care setting • Preferred: experience working with Medi-Cal and/or Medicare populations

🏖️ Benefits

• Robust and affordable medical coverage including HMO and PPO plan options • Employee Wellness Program promoting physical, mental, and financial well-being • Dental and vision plan with multiple provider choices • Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays, and 9 paid holidays) • CalPERS retirement pension program • Automatic employer-paid retirement contributions • Voluntary defined contribution plan • Two flexible spending accounts (FSAs) for healthcare and dependent care expenses • Employer-Paid Term Life and AD&D Insurance • Employer-Paid Disability Insurance • Employer-Paid Assistance Program (EAP) • Health Advocacy to help you navigate medical care and benefits • Voluntary supplemental benefits including medical, legal, identity theft protection • Online discount mall • Tuition reimbursement • Remote work contingent on business needs and company guidelines • Opportunity to work for a mission-driven organization

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