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Transitions of Care Nurse Baystate
Commonwealth Care Alliance is a rapidly growing nonprofit organization providing integrated health care and social support services to people with complex medical needs. Our patients are seniors and persons with disabilities covered under Medicaid or both Medicaid and Medicare. Our innovative care model is nationally recognized for its effectiveness in improving health outcomes for these vulnerable populations.
Our unique care model is empowering for our employees as well as our members. Whether you are a clinical or administrative professional, all of us at Commonwealth Care Alliance receive the satisfaction of knowing our work truly makes a difference. We enjoy a company culture of passionate advocacy in a supportive work environment with opportunities for growth and learning, competitive salaries, and a generous and comprehensive benefit package.
The RN Coordinator for Inpatient Management will review inpatient admissions for medical necessity and appropriate level of care, negotiating payment levels with facilities and assist with transition of care planning and coordination when a Commonwealth Care Alliance clinician is not already involved.
 Key Responsibilities:
Transitions of Care, RN
• Conduct telephonic preadmission, concurrent and retrospective clinical review of focused inpatient admissions at acute, rehabilitation and skilled nursing facilities though application of evidence-based medical necessity criteria, CCA policies and procedures, and regulatory and legislative requirements
 • Focus on effective and appropriate utilization of alternative levels of care
• Determine medical necessity and level of care based on the consistent application of decision support tools, and communicate decisions to facility, providers and member
 • Interact with facility staff and primary care to evaluate transition of care needs and prepare member and family for discharge
 • Coordinate authorization and/or delivery of post-acute care services
• Understand and appropriately manage member's benefits to maximize health care quality
 • Interface with Primary/Interdisciplinary Care Team including Care Coordinator, Care
 o Manager, and others to consult on clinical decision making, optimize member care and ensure safe and effective hand-offs and transitions
 • Position requires the ability to travel to facility or primary care sites within  Massachusetts
• Periodic coverage for colleagues serving members in the Senior Care Options Program and the Integrated Care Organization
 • After hours on call responsibility
Minimum Education Required: Bachelor's Degree or equivalent experience
Minimum Experience Required : 5 years
Knowledge, Skills and Abilities
• Exceptional customer service and interpersonal skills
• Ability to work effectively in team models
• Work in a fast paced environment
• Ability to work with all levels of personnel
Preferred Skills
• Negotiation
• Motivational interviewing
• BS in Nursing
• Licensure as a Registered Nurse
• 5-7 years minimum experience, combined clinical and utilization review
• Experience in care of the geriatric and/or complex medical population
• Experience in care management, utilization management, and care delivery systems
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