UM Transition of Care (TOC) Nurse- Bakersfield 1.1

Location: Bakersfield, CA. (Onsite)

Classification: Full-Time

This position is non-exempt and will be paid on an hourly basis.

Schedule:

Universal Healthcare MSO's standard operating hours are Monday through Friday, from 8:00 a.m. to 5:00 p.m. Pacific Time. Unless otherwise specified, all employees are expected to work their assigned schedules and remain available during these operational hours.

To support business operations and after-hours member needs, employees within the Utilization Management (UM) department may be assigned schedules that differ from standard business hours. Candidates accepting a position within the department should be aware that work schedules may be adjusted based on operational requirements. Currently, the anticipated alternate schedule for this role is 9:00 a.m. to 6:00 p.m.

Benefits:

· Medical

· Dental

· Vision

· Paid Time Off (PTO)

· Floating Holiday

· Simple IRA Plan with a 3% Employer Contribution

· Employer Paid Life Insurance

· Employee Assistance Program

Compensation: The initial pay range for this position upon commencement of employment is projected to fall between $31.00- $38.74 for CA Licensed LVN and $43.35-54.18 for CA Licensed RN. However, the offered base pay may be subject to adjustments based on various individualized factors, such as the candidate's relevant knowledge, skills, and experience. We believe that exceptional talent deserves exceptional rewards. As a committed and forward-thinking organization, we offer competitive compensation packages designed to attract and retain top candidates like you.

Position Summary:

The Utilization Management Transitions of Care (TOC) Nurse supports the Utilization Management (UM) department by conducting hospital bedside visits, engaging with members during inpatient stays, and facilitating timely, coordinated transitions from inpatient care to outpatient follow-up. This position requires regular travel to designated hospitals to visit hospitalized members in person. The TOC Nurse collaborates with hospital case managers, discharge planners, physicians, nursing staff, members, caregivers, primary care providers, and internal UM and care-management teams to identify potential clinical, functional, psychosocial, and logistical barriers that may affect discharge planning and continuity of care. The TOC Nurse gathers relevant clinical and demographic information, reviews available discharge plans and follow-up needs, communicates identified concerns to appropriate clinical personnel, and assists with coordinating post-discharge appointments and services. The nurse supports timely documentation and follow-up in accordance with established UM workflow, organizational policies, and applicable requirements.

The position serves as a liaison between the hospital and the IPA's Utilization Management and Care Coordination teams, helping bridge communication and workflows to support continuity of care. The TOC Nurse also assists with designated quality-measure activities by supporting follow-up, documentation, identification of care gaps, and coordination with members and providers as assigned. The RN or LVN performs duties only within the individual's licensure, education, training, and authorized scope of practice. Medical necessity determinations and authorization decisions are handled by appropriately authorized personnel under established policies and procedures.

Essential Duties and Responsibilities:

Hospital Visits and Bedside Member Engagement

· Travel to designated hospitals and conduct in-person bedside visits with assigned hospitalized members.

· Coordinate visits with hospital personnel in accordance with facility access, privacy, and infection-control requirements.

· Establish rapport with members and their families or caregivers using professional, compassionate, and culturally appropriate communication.

· Verify member demographics, contact information, primary care provider, specialists, caregiver information, pharmacy, and other pertinent information.

· Gather relevant information regarding the hospitalization, anticipated discharge plan, follow-up needs, and existing outpatient appointments.

· Identify potential barriers to a successful transition of care, including functional limitations, social needs, caregiver availability, transportation, medication access, and access to follow-up services.

· Communicate clinical concerns, changes in member status, and unresolved barriers to the appropriate licensed clinical personnel or treating team.

· Collaborate with hospital case managers, discharge planners, nursing staff, social workers, and other members of the interdisciplinary team.

· Respect member rights, preferences, confidentiality, and the member's right to decline a bedside visit.

Discharge Planning and Clinical Coordination

· Gather relevant clinical and discharge-related information to support UM and transitions-of-care workflows.

· Review available discharge instructions, medication information, recommended follow-up, and post-discharge service needs within the individual's licensure and scope of practice.

· Identify potential gaps in discharge planning, continuity of care, or access to recommended services.

· Communicate clinical concerns, discrepancies, and potential risks to the appropriate clinical personnel.

· Coordinate with hospital personnel to obtain discharge information and supporting documentation through established processes.

· Monitor anticipated discharge dates and communicate changes to the appropriate UM personnel.

· Support referrals to care management or other appropriate resources when additional assistance may be needed.

· Escalate urgent clinical concerns to appropriate treating or emergency response personnel in accordance with facility procedures and organizational protocols.

· Support discharge planning without independently directing treatment or making decisions outside the individual's authorized scope.

Transitions of Care and Outpatient Appointment Coordination

· Assist members with scheduling, confirming, and rescheduling primary care and specialty appointments following hospitalization.

· Coordinate follow-up appointments based on discharge instructions, provider recommendations, and established organizational workflows.

· Verify appointment dates, times, locations, provider information, and other relevant details.

· Communicate follow-up plans to members and caregivers in an understandable and culturally appropriate manner.

· Identify barriers to attending follow-up appointments, including transportation, scheduling, mobility, communication, and access to care.

· Communicate unresolved barriers to the appropriate UM or care-management personnel for further intervention.

· Assist with coordination of post-discharge services and referrals as assigned.

· Conduct post-discharge follow-up activities when indicated by established workflows or directed by UM leadership.

· Document appointment coordination, member outreach, identified barriers, interventions, and outcomes.

Utilization Management and Care Coordination Support

· Gather accurate member-specific information needed for timely and effective coordination of care.

· Communicate relevant clinical and nonclinical information to authorized UM personnel.

· Assist with identifying members who may benefit from additional clinical review, care management, or other appropriate services.

· Coordinate with UM nurses, physicians, hospital personnel, and other interdisciplinary team members to support continuity of care.

· Follow established UM policies, procedures, workflows, documentation standards, and escalation protocols.

· Ensure medical necessity determinations and authorization decisions are performed only by appropriately authorized personnel.

· Participate in UM initiatives and process-improvement activities related to discharge planning, transitions of care, and member experience.

Care Coordination Team Collaboration and Quality Measures

· Serve as a communication link between Utilization Management and the Care Coordination team to support timely referrals, handoffs, and continuity of care.

· Identify members who may benefit from Care Coordination outreach based on hospitalization, discharge needs, identified barriers, or established referral criteria, and route referrals according to workflow.

· Share relevant discharge plans, follow-up needs, and barriers with authorized Care Coordination staff using approved communication and documentation processes.

· Follow up on assigned handoffs to help ensure referrals and next steps are communicated and documented.

· Assist with designated quality-measure activities, such as identifying potential gaps in care, supporting member outreach, helping coordinate recommended follow-up, and documenting outcomes as assigned.

· Collaborate with UM, Care Coordination, Quality Improvement, providers, and other appropriate teams on initiatives intended to improve continuity of care and close identified care gaps.

· Maintain accurate, timely documentation of referrals, handoffs, member outreach, follow-up, and quality-related activities.

· Escalate unresolved barriers or concerns that may affect continuity of care or completion of quality-related follow-up to the appropriate team.

Documentation and Information Management

· Accurately and timely document bedside visits, member interactions, information obtained, discharge-related findings, identified barriers, interventions, and follow-up activities.

· Enter documentation into the designated electronic medical record, UM platform, or other approved system.

· Communicate pertinent findings and outstanding needs to the appropriate UM or clinical personnel.

· Obtain or assist with obtaining discharge summaries, discharge instructions, and other relevant documentation in accordance with established workflows.

· Maintain complete and accurate records of assigned activities and follow-up.

· Protect confidential member information and comply with HIPAA, organizational privacy policies, and applicable requirements.

· Ensure documentation is objective, factual, professional, and consistent with organizational standards.

Communication and Collaboration

· Establish and maintain effective working relationships with hospital case managers, discharge planners, nurses, physicians, social workers, provider offices, and IPA personnel.

· Communicate professionally and compassionately with members, families, and caregivers.

· Serve as a liaison between hospital teams and the organization's UM and care-management functions.

· Escalate clinical concerns, unresolved discharge barriers, and coordination issues to the appropriate personnel.

· Participate in department meetings, training, audits, and quality-improvement activities as assigned.

· Maintain appropriate professional boundaries and adhere to organizational and hospital policies while conducting bedside visits.

· Ability to recognize potential barriers to discharge and continuity of care and communicate concerns within the individual's scope of practice.

· Strong verbal and written communication, interpersonal, organizational, and problem-solving skills.

· Ability to interact effectively and compassionately with members, caregivers, providers, and interdisciplinary healthcare teams.

· Ability to maintain confidentiality and appropriately handle protected health information.

· Proficiency with electronic medical records, healthcare information systems, and Microsoft Office applications.

· Ability to work independently, manage assignments, prioritize competing responsibilities, and meet established deadlines.

· Ability and willingness to travel regularly to designated hospitals and other assigned locations to conduct bedside visits.

· Valid California driver's license, reliable transportation, and automobile insurance meeting applicable legal and organizational requirements.

· Ability to comply with hospital access requirements, infection-control practices, and workplace safety procedures.

Requirements

Required Qualifications:

· Current, active California Registered Nurse (RN) or Licensed Vocational Nurse (LVN) license in good standing.

· Graduation from a state-approved nursing program appropriate to the license held.

· Minimum of two years of nursing experience in an acute-care hospital, utilization management, case management, discharge planning, care coordination, or a related clinical setting.

· Knowledge of medical terminology, clinical documentation, inpatient care processes, and transitions-of-care principles.

· Ability to recognize potential barriers to discharge and continuity of care and communicate concerns within the individual's scope of practice.

· Strong verbal and written communication, interpersonal, organizational, and problem-solving skills.

· Ability to interact effectively and compassionately with members, caregivers, providers, and interdisciplinary healthcare teams.

· Ability to maintain confidentiality and appropriately handle protected health information.

· Proficiency with electronic medical records, healthcare information systems, and Microsoft Office applications.

· Ability to work independently, manage assignments, prioritize competing responsibilities, and meet established deadlines.

· Ability and willingness to travel regularly to designated hospitals and other assigned locations to conduct bedside visits.

· Valid California driver's license, reliable transportation, and automobile insurance meeting applicable legal and organizational requirements.

· Ability to comply with hospital access requirements, infection-control practices, and workplace safety procedures.

Preferred Qualifications:

· Bachelor's degree in Nursing (BSN) for RN candidates; additional education in nursing, healthcare administration, or care coordination is a plus.

· Three or more years of experience in utilization management, transitions of care, hospital case management, discharge planning, or care coordination.

· Experience working with an IPA, medical group, health plan, managed care organization, or hospital system.

· Familiarity with Medicare, Medi-Cal, Dual Eligible Special Needs Plans (D-SNP), and managed care requirements.

· Experience coordinating post-discharge appointments, referrals, and follow-up services.

· Familiarity with electronic UM platforms, authorization workflows, and clinical documentation systems.

· Experience identifying social determinants of health and barriers to access, including transportation, caregiver support, medication access, and community resources.

· Bilingual English/Spanish skills based on organizational and member population needs.

Knowledge, Skills, and Abilities:

· Knowledge of nursing practice, inpatient healthcare delivery, discharge planning, and transitions-of-care processes.

· Ability to review available clinical information and recognize potential risks or barriers to a successful transition of care.

· Strong assessment, observation, communication, and documentation skills appropriate to the individual's license and scope of practice.

· Ability to obtain accurate information through effective questioning, active listening, and professional interaction.

· Ability to establish rapport with hospitalized members and collaborate with hospital staff.

· Strong organizational skills, attention to detail, and follow-through.

· Ability to prioritize bedside visits, documentation, and follow-up activities in a changing healthcare environment.

· Ability to communicate concerns clearly and escalate issues to appropriate clinical personnel.

· Proficiency in electronic health records, UM systems, and other applicable technology.

· Ability to maintain professionalism in sensitive, stressful, and fast-paced hospital environments.

· Ability to travel between assigned hospitals and manage a field-based work schedule.

· Ability to coordinate referrals and handoffs between Utilization Management and Care Coordination.

· Ability to support assigned quality-measure workflows, member outreach, and care-gap follow-up.

Scope of Responsibilities:

The Utilization Management Transitions of Care Nurse functions within the UM department and performs duties according to organizational policies, procedures, training, licensure, and scope of practice. Responsibilities include hospital bedside engagement, clinical information gathering, identification and communication of potential barriers to discharge, transitions-of-care coordination, outpatient appointment assistance, documentation, and follow-up.

The RN or LVN does not independently make medical necessity determinations or approve or deny services unless specifically authorized under applicable policies, procedures, and role requirements. The nurse does not diagnose medical conditions, independently direct treatment, or provide clinical advice beyond the individual's authorized scope of practice. Duties requiring RN-level assessment, clinical judgment, or decision-making must be performed by an RN or other appropriately authorized clinician. Concerns outside the LVN's scope must be escalated to the appropriate RN, treating provider, or clinical leader.

Physical Requirements & Working Conditions:

Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions of this position.

This position is primarily performed in a professional office environment and requires the ability to:

· Regular travel to designated hospitals and other assigned locations is an essential function of the position.

· Frequent entry into hospital facilities and travel between patient rooms, hospital units, and clinical departments.

· Ability to walk, stand, and sit for extended periods while performing bedside visits and related duties.

· Ability to communicate effectively in busy hospital environments.

· Ability to interact professionally with members and families experiencing medical, emotional, or psychosocial stress.

· Ability to comply with hospital infection-control practices, personal protective equipment requirements, and workplace safety policies.

· May be exposed to clinical environments and infectious hazards associated with hospital settings.

· Must be able to perform the essential functions of the position, with or without reasonable accommodation.

· Work schedules may vary based on hospital needs, member assignments, and organizational priorities.