LE0010 InHealth Management, LLC

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MMM Holdings, Inc.Job Description Inpatient Unit POSITION: Concurrent Review Nurse (CRN)

POSITION DESCRIPTION

Manages the inpatient utilization of healthcare resources and develops, coordinates and implements the discharge plan, to ensure that the coordination and continuity of care results in optimal patient outcomes. Will adhere to the department policies related to the care of the Plans’ SNP members. Staff will attend all required trainings related to the MOC especially in areas of care management, ICP, ICT and health assessments. Staff will notify supervisors of any processes not in compliance with the Plan’s SNP policies and MOC requirements. Clinical staff who do not complete the required annual training may not perform their clinical duties until the training is completes.

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Performs daily visits to Acute, SNF, and Rehabilitation Inpatient facilities to concurrently review admissions and continued stay to determine appropriate Utilization, Quality Assurance, Risk Management and Discharge Planning Needs.2. Validates all Inpatient admissions for appropriate level of care within forty-eight (48) hours of admission on weekdays and within seventy-two (72) hours of admission on weekends.3. Develops and documents a discharge plan on each Inpatient within forty–eight (48) hours of having performed the first concurrent review of notified admission cases.4. On a daily basis, concurrently reviews all Inpatient care, on site or telephonically to validate appropriateness of services, lengths of stay and levels of care, utilizing nationally recognized Medical Care Guidelines approved by CMS, NCQA and MMM Healthcare, protocols a critical pathway.5. Develops, monitors, modifies and implements individualized transfer or discharge plans, to assure a timely discharge between levels of care and between facilities.6. Communicates regularly with the attending Physician/Hospital staffs regarding the patient’s status, any identified problems related to appropriateness of services, quality of care, or issues that may impact a timely discharge.7. Refers appropriate problems to the Plan’s Medical Director for intervention and resolution and confers daily regarding patient and physician related issues.8. Performs concurrent quality review and reports identified quality issues to the health plan’s and hospital’s Quality Improvement Department.9. Initiates the initial discharge assessment to all admission cases.10. Initiates referrals to DPU / Ambulatory Care Management and TU utilizing the health plan’s criteria for referrals.11. Researches community resources available to members, assesses the financial implications of a specific discharge plan, and develops a plan to most appropriately access those resources as well as covered benefits.12. Identifies aberrant Inpatient days, documents, and codes and reports the data to the Utilization Management Inpatient Coordinator and Inpatient Nurses.13. Captures required in – patient utilization data and forwards the information, daily, to the Utilization Management Inpatient Coordinator.14. Prepares and submits to the Health Services Department / UM Medical Care Manager a monthly report of activities performed.15. Attends all Utilization Management staff meetings and actively participates bi-monthly or monthly MSO IPAs Regional’s meetings.16. Daily concurrent and retrospective review documentation process in corporative electronically application in accordance with NCQA and CMS regulations to assure compliance standards and federal regulations utilizing established medical care guidelines.17. Performs additional duties, weekly reports and/or relevant to the position as requested by the Health Services Department Inpatient Medical Care Manager.18. Documents the discharge data in the Daily Census module MedHOK application of MMM/PMC.19. Collaborates and participates in all regional CRNs hospitals routes task forces to perform close cases on daily basis.20. Ensure, performs and follows the quality of services according to CMS, NCQA regulations and corporate processes and policies.21. Responsible on business day hours connected and attend regional conference calls with CRN Supervisor and Regional AIMDs by planned phone calls, following the department established processes according on daily basis.22. Participates on applications upgrades, testing and/or new tools implementations. 23. Performs additional job-related duties or special task as assigned by appointed CRNs Supervisor or Manager.24. CRN will be updating the primary and secondary Diagnosis to developed reports for the Model of Care to assure the adequacy to ensure quality report.25. Determinates necessity of services for Authorizations of Planned and Unplanned Transitions of Alternate Level of Care from acute admission and/or sub-acute Hospitals Discharges, including the outpatient admissions requests to Skill Nursing Facilities and/or Rehabilitation Centers.

EDUCATION AND EXPERIENCE

• Bachelor’s Degree in Science of Nursing. • Current R.N. permanent license in Puerto Rico and Collegiate. • Five years clinical acute care hospital experience; ICU, Emergency Medicine Department, Medical / Surgical Department. • One to three years experience in utilization management or health services setting preferred.

GENERAL SKILLS AND REQUIREMENTS

• Must possess a current Puerto Rico driver’s license and is able to commute to various facilities on any given day from the office work site.• Must have ability to work as a team player with excellent verbal and written communication skills.• Strong interpersonal skills.• Independent and a self – starter.• Ability to analyze and solve problems.• Familiarity with State Federal Governmental regulations and national accrediting agency requirement preferred (CMS/NCQA or regulatory agencies).• Availability to work flexible schedules including weekends and holidays.• Computer literate in Microsoft Windows applications, software and Internet.• Performs tasks requiring independent knowledge judgment in addition to instructions and procedures provided.• Must be able to function with frequent interruptions, accept change and be able to prioritize tasks efficiently when faced with competing demands.

LANGUAGE SKILLS

• Ability to speak, read and write in English and Spanish, preferable Bilingual in English to Spanish. • Ability to read, analyze, and interpret general business periodicals, operating and maintenance instructions, procedure manuals, professional journals, technical procedures, or governmental regulations. • Ability to write reports, business correspondence, and procedure manuals. • Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.

MATHEMATICAL SKILLS

• Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. • Ability to apply concepts of basic algebra and geometry. • Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

REASONING ABILITY

• Ability to define problems collects data, establish facts, and draw valid conclusions.

• Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.

INTERPERSONAL RELATIONS

Internal ContactsStaff employeesManagement at all levels of the organization

External ContactsExternal ProvidersExternal ClientsGovernment and Federal Agencies

PHYSICAL AND MENTAL DEMANDS

• Must be able to sit and stand for long periods of time with enough mobility to perform all job duties in the hospital an office environment. • While working the employee is standing, sitting, walking, talking, and listening most of the time. • The job also requires reaching objects with hands; stooping and bending to file and maintain orderliness; mobility to complete errands. • This job also requires lifting objects up to 10 pounds.

ENVIRONMENTAL AND WORKING CONDITIONS • Normal busy office environment. • Moderate noise (examples: business office with computers and printers, light traffic). • Travel required general exposure to weather conditions while traveling and different traffic situations.

This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.

If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!

Innovacare, Inc. is the leading provider of healthcare management in North America. Through two it’s main ways, Medicare Advantage and the provider network, we are committed to healthcare, creating models that are sustainable, cost-effective, and fully integrated with the most advanced technologies. Innovacare, Inc. combines innovation and quality care to create progressive, value-based models, even for the neediest patient populations. Our leadership team, with its vast years of combined experience in managed care and care delivery, is made up of leading experts with proven experience to help healthcare organizations effectively meet and exceed the growing demands of our industry.

InnovaCare Health's foundation was laid by President and CEO Richard Shinto, M.D., in 1998, when he joined North American Medical Management (NAMM) in California. Over the next 10 years, the company continued to grow, acquiring MMM Healthcare in Puerto Rico. In December 2012, the management team successfully sold select NAMM properties and officially formed InnovaCare Health to operate the remaining subsidiaries, including MMM. MMM Holdings, is a conglomerate of companies that work on Puerto Rico's business strategies, both for Medicare Advantage beneficiaries, through Medicare y Mucho Más (MMM), and for the beneficiaries of the government health plan with MMM Multihealth. Through InHealth Management, it manages the in-hospital care of the beneficiaries, while the specialized clinics, MMM Vita Care, serve members with chronic conditions. On the other hand, MSO of Puerto Rico supports medical groups, providers and other entities in the health industry, while Castellana Physicians Services is a medical group dedicated exclusively to providing services for the elderly and disabled population in Puerto Rico.

At the same time, the main company manages Medicare and Much More, a Medicare Advantage population health plan with a presence in Miami-Dade, Broward and Palm Beach counties. With a Mobile Application that allows members to check the status of their pre-authorizations, access their provider directory and schedule their future medical visits, Medicare and Much More integrates technology as a tool to improve the member experience. Also, the plan will ensure the health of members, during and after natural disasters. Through the Florida MMM Line of Care, as a Part D sponsor, you will ensure that the member has adequate access to their covered Part D drugs.

Orlando Family Physicians, a group of clinics that provide comprehensive care services in the state of Florida, is another of the companies managed by Innovacare, Inc. With more than 20 years of service in the Central Florida community and more than 100,000 patients cared, Orlando Family Physicians offers the personalized treatment and care that the patient deserves. With a track record that proves excellent customer service, we are proud that the largest Hispanic medical group in Central Florida has joined us. Our constant growth is the best witness we have to tell that things are being done well, so it is our commitment to continue on this path.

Innovacare, Inc. es el proveedor líder de manejo de servicios de salud en Norteamérica. A través de dos principales vías, Medicare Advantage y la red de proveedores, estamos comprometidos al cuidado de la salud, creando modelos que son sostenibles, costo-efectivos y completamente integrado a las tecnologías más avanzadas. Innovacare, Inc. combina innovación y atención de calidad para crear modelos progresivos y basados en el valor, incluso para las poblaciones de pacientes de mayor necesidad. Nuestro equipo de liderazgo con sus vastos años de experiencia combinada, en atención administrada y prestación de atención, está formado por expertos preeminentes con la experiencia comprobada para ayudar a las organizaciones de atención médica a satisfacer y superar eficazmente las crecientes demandas de nuestra industria.

Las bases de InnovaCare Health fueron establecidas por el presidente y CEO Richard Shinto, M.D., en 1998, cuando se unió a North American Medical Management (NAMM) en California. Durante los próximos 10 años, la compañía continuó creciendo, adquiriendo MMM Healthcare en Puerto Rico. En diciembre de 2012, el equipo de gestión vendió con éxito propiedades selectas de NAMM y formó oficialmente InnovaCare Health para operar las filiales restantes, incluida MMM.

MMM Holdings, es un conglomerado de compañías que trabaja las estrategias de negocio de Puerto Rico, tanto para Medicare Advantage, a través de Medicare y Mucho Más (MMM), como para los beneficiarios del plan de salud del Gobierno con MMM Multihealth. A través de InHealth Management maneja el cuidado intrahospitalario de los beneficiarios, mientras que, las clínicas especializadas, MMM Vita Care, atienden afiliados con condiciones crónicas. Por otro lado, MSO of Puerto Rico apoya grupos médicos, proveedores y otras entidades en la industria de la salud, mientras Castellana Physicians Services es un grupo médico dedicado exclusivamente a proveer servicios para la población de edad avanzada y discapacitada en Puerto Rico.

A su vez, la compañía matriz maneja Medicare and Much More, plan de salud para la población Medicare Advantage con presencia en los condados de Miami-Dade, Broward y Palm Beach. Con una Aplicación Móvil que permite a los afiliados verificar estatus de sus pre-autorizaciones, acceder su directorio de proveedores y agendar sus futuras visitas médicas, Medicare and Much More integra la tecnología como una herramienta para mejorar la experiencia del afiliado. También, el plan velará por la salud de los afiliados durante y después de desastres naturales. Por eso, a través de la línea de cuidado MMM de Florida, como patrocinador de la Parte D, se asegurará de que el afiliado tenga acceso adecuado a sus medicamentos cubiertos de la Parte D.

Orlando Family Physicians, grupo de clínicas que brindan servicios para el cuidado integral en el estado de la Florida, es otra de las compañías manejadas por Innovacare, Inc. Con más de 20 años de servicio en la comunidad de Florida Central y más de 100.000 pacientes atendidos, Orlando Family Physicians ofrece el tratamiento personalizado y la atención que el paciente merece. Con una trayectoria que prueba un excelente servicio al cliente, estamos orgullosos de que el grupo médico hispano más grande en Florida Central se haya unido a nosotros. Nuestro constante crecimiento es el mejor testigo de que las cosas se están haciendo bien por lo que es nuestro compromiso continuar por ese camino.