Utilization review nurse Jobs in Moreno Valley, CA

Community health is about more than just vaccines and checkups. It’s about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We’re with you every step of the way, with the care you need for each of life’s chapters. At Neighborhood, we are Better Together.

Neighborhood Healthcare PACE is a managed medical plan built around surrounding participants with a team of physicians, nurses, social workers, therapists and care coordinators to help them maintain good health and a good quality of life. Our goal is to keep our seniors happy and healthy at home surrounded by their family and community.

As a private, non-profit 501(C) (3) community health organization, we serve over 500k medical, dental, and behavioral health visits from more than 100,000 people annually. With two PACE centers located in Riverside County, our PACE program is positioned to serve over 650 senior participants.

The Utilization Management (UM) and Transitional Care Nurse Navigator/Liaison is responsible for building strong relationships with local hospitals, skilled nursing facilities (SNFs), and other care providers to ensure smooth transitions of care for PACE participants. The role focuses on improving care coordination, fostering collaboration, and ensuring compliance with federal and state regulations while enhancing the participant’s experience. Schedule: Monday-Friday, 8am-5pm. This position is onsite.

Responsibilities

Care Coordination and Transition Management

• Act as the primary point of contact for transitions between hospitals, SNFs, and home care settings.
• Ensure timely and effective communication among all stakeholders, including physicians, discharge planners, and PACE interdisciplinary teams (IDTs).
• Monitor participant transitions to ensure compliance with regulatory requirements, including the timeliness of physician visits and follow-ups.
• Follow up on participant hospitalizations to ensure proper transitions to SNFs or home, ensuring compliance with new and existing regulations.

Relationship Building

• Develop and maintain strong relationships with Directors of Nursing, Case Managers, and other key staff at local hospitals and SNFs.
• Serve as a liaison to build trust and streamline communication between PACE and external providers.

Weekly Facility Visits

• Conduct weekly visits to contracted facilities to maintain a physical presence and reinforce relationships.
• Address any care-related concerns promptly and ensure participants receive quality care aligned with their care plans.

Regulatory Compliance

• Ensure all transitions of care meet the requirements outlined in federal regulations, including 42 CFR §483.30.
• Maintain accurate documentation of participant care and transitions in compliance with regulatory and organizational standards.

Team Collaboration

• Participate in IDT meetings to update the team on participant transitions and facility interactions.
• Collaborate with medical directors and providers to align care plans and ensure consistency of orders, medications, and treatments.

Access to EMRs

• Obtain and maintain access to facility electronic medical records (EMRs) to monitor participant care effectively.
• Document relevant participant data to support care coordination and oversight.

Oversight of Clinical Processes

• Oversee and ensure the timely completion of all required physician visits, including initial visits and routine follow-ups.
• Ensure orders for medications and treatments are in place and meet participant needs during transitions of care.

Participant Advocacy

• Serve as an advocate for PACE participants to ensure they receive appropriate care during transitions.
• Educate participants and their families on care plans and post-discharge instructions.

Participant-to-Navigator Ratio

• The Nurse Navigator/Liaison will support up to 325 PACE participants to ensure effective care coordination and compliance.
• Perform other duties as assigned in support of departmental and organizational goals

Qualifications

Education/Experience

• Bachelor’s degree in nursing required
• Valid CA Registered Nurse License required. Registered Nurse (RN) with an active, unrestricted license to practice in the state.
• Minimum of 3 years of clinical nursing experience required, with at least 1 year in transitional care, case management, or utilization review. Experience in PACE, SNFs, or hospital settings is preferred
• Current Basic Life Support (BLS) certification through an American Heart Association (AHA) approved source is required upon hire and must be maintained as a condition of employment. AHA-approved courses include an in-person, hands-on skills check with a certified instructor using a mannequin to demonstrate CPR and emergency response techniques Online-only BLS courses without a live skills check do not meet this requirement In addition, current CPR and First Aid certification are required for all PACE employees in accordance with CMS and DHCS requirements. First Aid training will be provided at onboarding and must be renewed annually
• Valid CA driver's license and proof of auto insurance required
• Experience working in risk-based integrated models of care preferred
• Certification in Case Management (CCM) or equivalent preferred

Additional Qualifications (Knowledge, Skills and Abilities)

• Excellent verbal and written communication skills, including superior composition, typing and proofreading skills
• Ability to interpret a variety of instructions in written, oral, diagram, or schedule form
• Ability to use data to drive decisions and collaboration with internal and external stakeholders
• Excellent strategic thinking, problem solving, and decision-making skills
• Ability to apply leadership skills to motivate and guide teams toward timely and efficient care management strategies
• Ability to successfully manage multiple tasks simultaneously
• Excellent planning and organizational ability
• Ability to work as part of a team as well as independently
• Ability to work with highly confidential information in a professional and ethical manner

Physical Requirements

• Ability to lift/carry 10 lbs/weight
• Ability to stand for extended periods of time
• Ability to travel locally to facilities and participant homes.
• Physical capacity to walk and stand for extended periods during facility visits.

Neighborhood Healthcare offers a generous benefit plan that includes: Medical, Dental, and Vision Plans. Two plus weeks of vacation, Nine Holidays including two Floating Holidays of your choosing, Sick/Personal time, Volunteer Time Off (VTO), 403b Retirement plan (similar to a 401k), optional Health and Wellness events, and much more!

Pay range: $50.10 to $75.10 per hour, depending on experience.

Compensation Disclosure: The posted salary range reflects the designated pay grade for this position. While this range represents the broader classification of the role, actual compensation will be based on several factors, including but not limited to: the candidate’s overall knowledge, skills, and experience, market data and industry benchmarks, internal equity within the organization, Budgetary considerations and organizational needs. As a result, placement within the range is not guaranteed, and the full pay grade range may not be utilized.