Job Title: PAC Nurse

Job Description

The PAC Nurse is a telephonic position responsible for recommending discharge plans, assisting with transition of care, and managing the length of stay (LOS) for Long Term Acute Hospital, Skilled Nursing Facility (SNF), and Institutional Rehab Facility (IRF) for their assigned and non-assigned post-acute care (PAC) facilities through collaboration. The PAC Nurse will collaborate with key facility personnel and internal Medical Directors, Market Engagement Directors, and Nurse Managers to develop and maintain a timely discharge plan.

Responsibilities

• Collaborate with the PAC Medical Director as needed to ensure proper medical necessity decisions are being rendered.
• Partner closely with the PAC Medical Director in care planning and goal setting, reviewing discharge plans and length of stay status to ensure optimal outcomes.
• Act as a clinical resource for unlicensed Post-Acute Care Coordinators, providing clinical expertise and helping to clarify referral source directives.
• Receive/respond to requests from unlicensed staff regarding scripted clinical questions and issues.
• Act as the primary contact to the post-acute facility or facilities to which they are assigned to obtain all clinical information required and to proactively obtain patient status updates.
• Work alongside the Supervisor, and work closely with Market Engagement Directors to efficiently address potential facility concerns, pushback, or gaps in process.
• Communicate customer service/provider issues to the supervisor for logging and resolution.
• Conduct scheduled telephonic touch points with each facility point person to review each member within that facility and confirm appropriateness for continued stay.
• Authorize continued stay at SNF, IRF, and Home Health care (if delegated) using approved medical care guidelines and collaboration with key facility personnel within the healthcare setting.
• Use clinical expertise, review clinical information, and clinical criteria to determine if the service/device meets medical necessity for the member.
• Ensure case review and elevation to complete the determination is rendered within the contractual and regulatory turnaround time standards to meet both contractual and regulatory requirements.
• Participate in performance and operational improvement activities.
• Participate in and contribute to ongoing quality assessment/improvement activities, ensure the collection of data for improvement analysis, and prepare reports as requested.
• Assist team in implementing and maintaining standardized operational processes to ensure compliance with company policies, legal requirements, and regulatory mandates.
• Participate in special projects and perform other duties as assigned.
• Participate in an annual Inter-rater reliability Testing Process.
• Carry a typical work schedule. Based on business needs, evening and weekend coverage will be needed at times.

Essential Skills

• Excellent negotiation, influencing, problem-solving, and decision-making skills.
• Excellent communication (verbal/written), organizational, and interpersonal skills.
• Ability to work independently, utilizing sound clinical judgment and critical thinking skills under minimal supervision.
• Strong commitment to quality and standards.
• LPN or RN license.
• Post-acute nursing experience (i.e., Inpatient Rehab Facility, Long-Term Acute Care Hospital, Skilled Nursing Facility).
• 3 years of concurrent review experience and/or discharge planning.
• 2 years of utilization review/management experience.
• 1 year of experience within Case Management or Transition-of-care role.

Additional Skills & Qualifications

• Comfortable speaking with providers/offices via phone.
• Interqual experience.
• Milliman/MCG experience.
• Current and unrestricted LPN or RN license.
• Associate's Degree or Diploma in Nursing/Practical Nursing.
• Minimum of 2 years of clinical experience in a clinical setting.
• Experienced in Utilization Management and knowledge of URAC & NCQA standards.
• Broad knowledge of healthcare delivery/managed care regulations and experience with evidence-based care guidelines (i.e., MCG/Milliman, Interqual).
• High level of clinical knowledge, communication, customer service, and problem-solving skills, as well as the ability to effectively interact with all levels of management and a highly diverse clientele.
• Strong organizational skills.
• Strong time management skills.

Work Environment

Work From Home - Equipment provided. First 3 weeks are training - you must not miss any training days! (If candidate has a scheduling conflict with training, DO NOT SUBMIT). Training schedule: Monday-Friday 8:00am-4:40pm EST. Contract schedule Post Training: Monday-Friday 11am-7:30pm EST (30-minute lunch break). Candidates from PST and MST can be submitted to align better with the schedule.