Emergency Prospective Review Nurse, Hybrid, Full-time, FTE 12HR, 8:30am -9am

apartment PIH Health location_onDowney, CA 90241, US

PIH Health is a nonprofit, regional healthcare network that serves approximately 3 million residents in the Los Angeles County, Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Hospital - Whittier, PIH Health Hospital - Downey and PIH Health Good Samaritan Hospital, 27 outpatient medical locations, a multispecialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer, women’s health, urgent care and emergency services.

The organization is recognized by Watson Health as one of the nation’s Top Hospitals, and College of Healthcare Information Management Executives (CHIME) as one of the nation’s top hospital systems for best practices, cutting-edge advancements, quality of care and healthcare technology. PIH Health is certified as a Great Place to Work ^TM. For more information, visit PIHHealth.org or follow us on Facebook, Twitter, or Instagram.

The Emergency Prospective Review (EPR) Nurse – RN has the responsibility to conduct a review of all patients requiring hospital admission from the emergency room at all PIH and non-PIH facilities (for PHP members) 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 patient’s insurance and various payors to coordinate and assist with reparation/transfer of out-of-network patients from PIH facility to the patient’s 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.

Required Skills

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

Required Experience

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

Address
11500 Brookshire Ave.

Salary
55.00-87.50

Shift
Nights

Zip Code
90241

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