Concurrent Review​/Transition of Care Nurse, RN

We’re delighted you’re considering joining us! At Hill Physicians Medical Group, we’re shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions, and anticipates the needs of our members.

Hill Physicians has been recognized as one of the “Best Places to Work in the Bay Area” and as one of the “Healthiest Places to Work in the Bay Area.”

At Hill Physicians, your uniqueness is valued, celebrated, encouraged, supported, and embraced. We welcome everyone who joins our team. We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities.

We do it because it’s right.

Responsible for proactively assisting in the transition of care process by demonstrating collaborative action to facilitate smooth transitions through varying levels of care and throughout the care continuum. Monitor inpatient utilization, assist with facilitation of the discharge or transfer plans and provide discharge follow up to assure that medical care is appropriate and efficient.

• Support the interdisciplinary team approach to ensure effective resource utilization, as well as quality and cost‑effective outcomes.
• Follow designated TOC workflows to assure consistency and accountability.
• Monitor inpatient utilization according to identified criteria.
• Facilitate discharge planning.
• Proactively and collaboratively interface with physicians, hospital staff, members and their families to assist in expediting appropriate discharge.
• Serve as a liaison between the hospital, health plan, vendors, and providers.
• Coordinate internal and external resources for the individual member.
• May provide telephonic post‑hospital follow‑up to assure members understanding of the discharge instructions and current treatment plan.
• Determine what home services were ordered at the time of discharge and assure that services ordered have been received or activated.
• Provide medication reconciliation and refer to pharmacist as warranted.
• Assure member is established with appropriate providers and is receiving appropriate and timely follow‑up.
• Assess for any issues that may require ongoing case management.
• Assure member has adequate support.
• Support a positive work environment and foster teamwork.
• Maintain client privacy, safety, confidentiality, and advocacy while adhering to ethical, legal, regulatory and accreditation standards.
• Maintain department procedure/policy standards with regard to turnaround time, etc.
• Abide by and maintain telecommuting standards.
• Adhere to the policy and procedures of assigned hospital(s).
• Meet Care Coordination attendance and availability standards.
• Build and maintain appropriate relationships on behalf of HPMG.

• Minimum three years clinical nursing experience in an area such as medical surgical, critical care, home health or skilled nursing with two years of managed‑care experience preferred.
• Possess optimum organizational skills with the ability to meet both expected and unexpected time frames.
• Proficient in MS Office applications and other computer skills.
• Ability to coordinate effectively with a variety of customers including members, providers, office staff, health plans, internal department, community resources, and peers.
• Active, unrestricted California Registered Nursing License.

Salary: $110,000 - $120,000 Annual.

Hill Physicians is an Equal Opportunity Employer.