PRINCIPAL RESPONSIBILITIES:

　　Under general direction of the Manager of Long-Term Care and working in cooperation with other departments, such as Utilization Management, the Long-Term Care (LTC)) Nurse Specialist RN is responsible for providing health plan administrative support and clinical support to Members on the admissions and continued stay services in LTC Nursing Facilities/Intermediate Care Facilities/Distinct Part Hospitals. The position with provide clinical judgment and critical thinking skills to determine the appropriateness of LTC admissions as well as ongoing continued stay evaluations. The position will collaborate with the LTC facilities to ensure appropriate physical and behavioral healthcare and social services are provided timely and efficiently for the Alliance members. Utilizes assessments, member-centered care planning, direct provider

　　coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization available to Members. The LTC Nurse Specialist will possess knowledge of current upcoming programs and services that intersect with LTC services, Enhanced Case Management, Community Support, Population Health Management, Regional Services, HCBS (Home and Community Based Services).

　　The position will be responsible for supporting collaboration with Skilled Nursing Facilities (SNF) and Provider Medical Groups (PMG) to facilitate and coordination authorization of services under the responsibility of the delegated PMG. The position will coordinate the identification, documentation, and resolution of LTC facility related issues in a timely manner.

　　ESSENTIAL FUNCTIONS OF THE JOB

　　Performs clinical review of Skilled Nursing Facilities (NF-A/B), Distinct Part Hospitals and Intermediate Care Facility admissions and recertifications to validate the appropriate level of care.Responsible for performing assessments of members referred to health plan programs for the identification, evaluation, coordination, and management of members' needs, including physical health, behavioral health, and social services.Provides direction to non-clinicians who assist members with accessing services.Conducts additional assessments as necessary, to monitor, evaluate and revise members' care plans to meet members' needs, with the goal of optimizing member health care across the care continuum. Arranges for all services required while coordinating with the health care team to eliminate duplication of services.Interfaces with Medical Directors, social workers, and interdisciplinary care team (ICT). Participates in ICT meetings and makes recommendations for LTC programs.Establishes relationships with referral sources and community resources, such as external providers, SNFs, CBAS Centers, PMGs, and care coordinators, while maintaining strict member confidentiality and complying with all Health Insurance Portability and Accountability Act (HIPAA) requirements.Facilitates care coordination with internal and external entities to improve member's short- and long-term goals in collaboration with member, caregivers, family, support systems, and physicians. A person-centered approach will minimize member confusion and ensure that the best care is delivered in the most appropriate setting.Supports the Community Transition programs by evaluating identified institutional Members to determine if needs can be addressed through other avenues, such as, community services, HCBS and covered health plan benefits, and makes referrals to appropriate programs.Documents accurately and comprehensively based on the standards of practice and current organization policies.Performs other duties as assigned.ESSENTIAL FUNCTIONS OF THE JOB

　　Performs clinical review of Skilled Nursing Facilities (NF-A/B), Distinct Part Hospitals and Intermediate Care Facility admissions and recertifications to validate the appropriate level of care.Responsible for performing assessments of members referred to health plan programs for the identification, evaluation, coordination, and management of members' needs, including physical health, behavioral health, and social services.Provides direction to non-clinicians who assist members with accessing services.Conducts additional assessments as necessary, to monitor, evaluate and revise members' care plans to meet members' needs, with the goal of optimizing member health care across the care continuum. Arranges for all services required while coordinating with the health care team to eliminate duplication of services.Interfaces with Medical Directors, social workers, and interdisciplinary care team (ICT). Participates in ICT meetings and makes recommendations for LTC programs.Establishes relationships with referral sources and community resources, such as external providers, SNFs, CBAS Centers, PMGs, and care coordinators, while maintaining strict member confidentiality and complying with all Health Insurance Portability and Accountability Act (HIPAA) requirements.Facilitates care coordination with internal and external entities to improve member's short- and long-term goals in collaboration with member, caregivers, family, support systems, and physicians. A person-centered approach will minimize member confusion and ensure that the best care is delivered in the most appropriate setting.Supports the Community Transition programs by evaluating identified institutional Members to determine if needs can be addressed through other avenues, such as, community services, HCBS and covered health plan benefits, and makes referrals to appropriate programs.Documents accurately and comprehensively based on the standards of practice and current organization policies.Performs other duties as assigned.PHYSICAL REQUIREMENTS

　　Constant and close visual work at desk or computer.Constant sitting and working at desk.Extensive data entry using keyboard and/or mouse.Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.Occasional travel to hospitals and other facilities.Frequent lifting of folders and other objects weighing between 0 and 30 lbs.Frequent walking and standing.Occasional driving of automobiles.Occasional travel between offices for meetingsNumber of Employees Supervised: 0

　　MINIMUM QUALIFICATIONS:

　　EDUCATION OR TRAINING EQUIVALENT TO:

　　Associate of Science in Nursing or Accredited Diploma Nurse School, required.Bachelor of Science in Nursing or related field or equivalent experience preferred.Master of Science in Nursing or Health Administration or related field preferred.Licenses/Certifications

　　Registered Nurse (RN) - Active, current, and unrestricted California License, requiredActive and Current Driver's License, with a clean record and Auto Insurance, requiredMINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

　　Minimum two years of clinical experience, requiredMinimum two years of experience in managed care health plan, hospital, skilled nursing or similar setting, required.SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

　　Experience with Medi-Cal and Medicare populations and regulatory requirements.

　　Knowledge of DMHC regulations and DHCS contractual requirements.

　　Experience in utilization review, skilled nursing services, home health, discharge planning, behavioral health, community resources, and/or other home and community-based agencies

　　Working knowledge of case/care management principles

　　Work