Nurse Practitioner (Ocean, New Jersey)

Overview:

As the Nurse Practitioner- Post Acute Care you will provide clinical oversight for one or more CareCentrix markets including Utilization Management reviews of Post-Acute Care (PAC) stay requests, medically appropriate steerage to home, coordination of discharges, in facility readmission management and post discharge follow up to prevent readmissions. A key part of the role is to work strategically with Onsite Nurse Liaisons and market engagement directors to overcome facility barriers to discharge. Peer-to-Peer conversations with hospital, IRF and SNF physicians either pre or post denials, as needed to impact PAC facility admissions and concurrent reviews. Clinical rounds with nurse teams to support PAC length of stay and readmission management. In this role, the Nurse Practitioner will perform medical necessity reviews utilizing industry standard criteria such as InterQual or MCG and CMS. The primary work will involve PAC facility management including Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF) and/or Long-Term Acute Care Hospital (LTCH). The Nurse Practitioner is also responsible for developing trainings and quality improvement interventions to support optimal PAC outcomes including readmission prevention program.

• Manage oversight for all performance guarantees for health plan clients within assigned market/region and PAC Facility metrics for program quality and contract compliance.
• Identify and implement performance improvement both clinical and non-clinical to result in better patient outcomes
• Make periodic and strategic facility rounds to ascertain relationship status, clinical integration and facility receptivity.
• Conduct market-based Hospitalization Review Meetings collaboratively with Market Director, ensure follow-up actions, accuracy of hospital tracking data and adherence to regulatory and compliance turnaround times.
• Ensures Clinical and quality programs are delivered in accordance with state and federal regulations, accreditation and health plan objectives.
• Provide guidance to licensed and non-licensed associates on clinical and non-clinical issues and case reviews related to authorization requests, clinical guidelines criteria and readmission issues.
• Provide education to Nurse Liaison (NL) – onsite in acute and PAC facilities, PAC Nurse, and Utilization Management (UM) teams to support Post Acute Care needs, discharge planning, length of stay management and readmission reduction.
• Complete pre-peer-to-peer discussions as indicated at the time of PAC facility admissions when medical necessity criteria are not met, to facilitate proactive discharge planning or when facility stay is no longer medically indicated.
• Facilitate delivery of complete clinical documentation including discussions with facilities to MD for escalation for denial
• Participates in CareCentrix Care Coordination, Utilization Management, Quality Improvement and clinical education activities, as requested.
• Utilize clinical integrity and professionalism in all determinations and interactions with internal and external partners.
• Collaborate closely with Market Engagement to ensure strong relationships with PAC facilities are maintained and grown and assure PAC Facility relationships with stakeholders.
• Perform ongoing reviews of hospitalization and invention metrics.
• Collaborate with Market Engagement Directors and facility provider Joint Operations Committee activities as requested/needed.
• Work in conjunction with Market Engagement for PAC facility readiness evaluations, and/or recommendation to clients on partnership adjustments.
• Collaborate with Account Management and Health Plan clinical leadership as requested.
• Interface with key positions within CareCentrix including the Senior Medical Director and interacting with the Chief Medical Officer and executive team members.
• Create and ensure delivery of standards and policies within budgetary guidelines and effective clinical workforce for supporting clinical and operational processes.
• Complete and pass the annual Inter-rater reliability testing and random case audits.
• Achieves Service Level Agreement (SLA) metrics as required by health plan clients and identifies risks of effective execution and implements mitigation plans.
• Led innovation and special projects aimed at improving member outcomes.
• Develop and implement cost effective clinical staffing plans and training programs for optimal market performance.
• Perform other duties as assigned.
• Scheduled weekend work is required.

Qualifications:

• Master’s degree in nursing and Licensed as an advanced practice nurse in home state, ANCC or AANP Board certified. Specialty in Geriatrics or Adult preferred.
• Confirmation of state licensure requirements for practice authority.
• Minimum of 5 years’ experience in an area of relevant clinical practice and prefer at least 3 years’ experience with supporting utilization management reviews, managed care programs or care delivery networks.
• Expertise in execution and improving outcomes in patient care in the Post Acute care field
• Expertise in the Post-Acute Care field, including current knowledge on best practices, as well as a general knowledge of requirements of regulatory and accreditation standards for payers and health care providers.
• Excellent written and verbal communication skills.
• Strong interpersonal skills a must for effectively enhancing relationships with the communities we serve, including the internal organization.
• Interest quality improvement and project a positive attitude toward all assigned work.
• Adheres to and participates in Company's mandatory HIPAA privacy program / practices and Business Ethics and Compliance programs / practices.
• Computer proficiency, including Microsoft Office Suite.
• Ability to learn and successfully utilize electronic medical records and other clinical software.
• Able to work independently with minimal supervision getting results in a fast‐paced environment.
• Must have strong knowledge of the healthcare community in the assigned market area.
• Valid state driver's license with a good driving record and proof of automobile insurance required.

Preferred Skills:

• Clinical background working in nursing homes or supervising staff in nursing homes, Clinical Quality Program design, Utilization Management Plan implementation, working in a managed care plan/risk bearing entity.
• Leading and managing clinical affordability initiatives.
• Successful experience in managing a team of professionals (NPs, RNs, etc.) to achieve overall program/health plan goals.
• Ability to stay on top of trends in the health care industry with particular focus on competitive analysis, growth, innovation and clinical technology.
• Ability to compile and analyze data to be used for management, differentiation, and marketing purposes.
• Excellent public presentation skills.
• Highly organized and able to manage multiple projects, people and deadlines at one time.

What we offer:

• Pay Range: 
• Full range of benefits including Health, Dental, and Vision with HSA Employer Contributions and Dependent Care FSA Employer Match.
• Bonus Incentives, Generous PTO, 401K Savings Plan, Paid Parental Leave, free on-demand Virtual Fitness Training and more.
• Advancement Opportunities, professional skills training, and tuition /exam reimbursement.
• PayActiv - access earned income in between pay checks.
• Walgreens Discount - receive up to 25% off eligible items.
• Great culture with a sense of community.

CareCentrix maintains a drug-free workplace.

#IDCC

We are an equal opportunity employer. Employment selection and related decisions are made without regard to age, race, color, national origin, religion, sex, disability, sexual orientation, gender identification, or being a qualified disabled veteran or qualified veteran of the Vietnam era or any other category protected by Federal or State law.

CareCentrix accepts applications on an ongoing basis until a candidate is identified.