Inpatient Review Nurse

General Description
HPSM seeks an Inpatient Review Nurse to ensure that initial and concurrent reviews for all inpatient admissions are completed within specified timeframes using evidence-based criteria to determine medical appropriateness and support the appropriate level of care. This role also involves coordinating clinical needs across the continuum of care by establishing communication and collaboration with physicians, healthcare providers, and community resources.
Qualifications
The following represents the typical way to achieve the necessary skills, knowledge and ability to qualify for this position:
Education and Experience

• Associate or bachelor’s degree in nursing.
• Two (2) years clinical nursing experience.

Skills

• Advanced application of clinical guidelines (e.g., Milliman, InterQual).
• Advanced verbal and written communication skills.
• Intermediate customer service delivery skills.
• Advanced independent problem-solving and decision-making skills.

Knowledge

• Advanced knowledge of case management principles.
• Advanced knowledge of managed care processes.
• Intermediate knowledge of federal, state, local, and regulatory healthcare requirements.
• Intermediate knowledge of community resources and support systems.
• Intermediate knowledge of personal computer operations and Microsoft Office Suite.

Abilities

• Advanced ability to work cooperatively with others.
• Advanced ability to work as part of a team and support team decisions.
• Advanced ability to adapt to changing priorities and requirements.
• Advanced ability to work independently with minimal supervision.
• Intermediate ability to provide excellent customer service.
• Advanced ability to communicate clearly and effectively in both verbal and written forms.

Licensure/Certifications

• Valid California license as a Registered Nurse or Licensed Vocational Nurse.
• Certification as a Certified Case Manager (CCM) preferred.

Driving

• Not applicable.

Duties & Responsibilities
Essential Functions
Utilization Management

• Perform proactive management of acutely and chronically ill members to improve quality outcomes and reduce utilization costs.
• Provide utilization management, including transfer coordination, discharge planning, and issuing authorizations for covered services.
• Reconcile daily hospital census reports and face sheets against authorizations to ensure accuracy and appropriate tracking of inpatient admissions.

Care Coordination

• From the day of admission, collaborate with facility partners to evaluate and provide feedback to admitting physicians and discharge planners on anticipated discharge plans and service coordination.
• Coordinate an interdisciplinary approach to support continuity of care across settings.
• Collaborate with the Care Transitions Unit to support safe and timely transitions from inpatient to post-acute care settings.
• Identify and assess members early for potential inclusion in a comprehensive case management program.
• Refer eligible members to Case Management for further assessment and long-term care coordination support.
• Complete all required documentation and member follow-up calls within specified systems and timeframes to ensure regulatory compliance and continuity of care.

Secondary Functions

• Maintain a valid California Registered Nurse or Licensed Vocational Nurse license.
• Support other departmental goals or projects related to utilization management and care coordination as needed.
• Perform other duties as assigned.

Pay rate is dependent on experience and licensure (RN, LVN).