American Care is "Where You Belong" Joining our Fast Growing Company is the Best Decision for your Career Development Company Benefits Company's 401(k) Retirement Plan; Paid time off per Company's Policies; Paid holidays off per Company's Policies; Health, dental, and life insurance per Company's Policies; Colonial Life Voluntary/Supplemental Benefits; and Full access to American Care's Premier Healthcare Plan. Healthcare Providers Recruiter Essential Job Functions Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Utilization Monitoring & Data Entry Review all ER visits and daily hospital census reports received from contracted health plans. Enter ER visit and hospitalization notification information, along with any supplied medical records, into the EMR. Monitor admissions and discharges on an ongoing basis. Discharge Planning & Follow-Up Coordination Confirm that medication reconciliation occurs within 3 days of discharge and is properly documented. Coordinate post-discharge follow-up appointments. ER Diversion & Care Coordination Coordinate activation of Nursing Services, free Transportation, Pharmacy delivery, Nutrition/Hygiene Support, Social Assistance, and Behavioral Health services for high utilizers and post-discharge patients. Reporting & Outlier Review Review health plan ER and hospital utilization reports, with particular attention to members with high utilization of ER and hospital services. Identify members requiring additional review, including extended hospital stays (greater than 7 consecutive days), recurrent hospitalizations, frequent ER utilization (≥3 visits in 6 months or a rising trend), and other utilization trends requiring intervention; refer outliers for additional case management. Documentation & Quality Improvement Ensure all ER and hospitalization reviews, recommendations, follow-up activities, provider communications, and utilization reports are documented within IPHES, including prior-contact information, diversion attempts and outcomes, and resource activations. Support integration of ER/hospitalization utilization data into the organization's Quality Improvement Program, including tracking Stars quality ratings and additional QI metrics (non-emergent ER visits preceded by contact, ER-to-Urgent-Care conversion rate, Nursing Services activation rate, SDOH screening/intervention rates, and center-level utilization variation). Required Education and Experience Active Registered Nurse (RN) license or relevant clinical/health services credential preferred; equivalent combination of education and utilization management experience considered. Minimum of 2-3 years of experience in utilization management, case management, care coordination, or a managed care clinical operations role. Experience with health plan reporting, hospital census/discharge processes , and clinical documentation systems preferred. Any combination of education, training, and experience which demonstrates the ability to perform the duties and responsibilities as described including related work experience. IND1

Pay:

Up to $82,000.00 per year

Benefits:

401(k) 401(k) matching Dental insurance Employee assistance program Employee discount Health insurance Life insurance Paid time off Parental leave Referral program Retirement plan Vision insurance Application Question(s): Are you a Registered Nurse (RN)?

License/Certification:

RN License (Required) Willingness to travel: 50% (Required)

Work Location:

In person