Nursing Jobs in Diamond Bar, CA
$102,000 - $115,000 / year
Manager - Risk Adjustment Department: Quality - Risk Adjustment Employment Type: Full Time Location: 600 City Parkway West 10th Floor, Orange, CA 92868 Reporting To: Nallammai Vijayakumar Compensation: $102,000 - $115,000 / year Description Astrana Health is seeking Manager - Risk Adjustment to oversee risk adjustment initiatives for the organization, including in-home health assessments, embedded NP, medical chart retrieval, HCC risk adjustment data & documentation integrity, and supporting vendor programs. This manager will also oversee implementation of programs designed to ensure all diagnosed codes and conditions are properly supported by appropriate documentation in patient chart. These programs include but are not limited to training and educational activities, Nurse Practitioner and AWV programs, clinical chart review programs, retrospective reviews, encounter submission, data reconciliation, and electronic data submission including supplemental data submissions Our Values: Put Patients First Empower Entrepreneurial Provider and Care Teams Operate with Integrity & Excellence Be Innovative Work As One Team What You'll Do Oversees daily regional operations of the coding and specialists’ team, retrospective and prospective review teams and programs and ensures the appropriate strategy, tactics and data capture processes are in place. Collaborate closely with providers and regional network leadership teams to implement risk adjustment education, processes, and programs effectively for accurate and compliant capture of members' conditions. Identify and analyze implications of key changes to the regulatory & policy environment on provider organizations in the areas of risk adjustment and compliance. Serves as the vendor(Chart review/AWV /Cozeva etc) and provider liaison to ensure coordination of efforts, effective relationship management, cost effectiveness, delivery of work product, quality of work, delivery of required training for internal associates and timely communication on all issues. Manage the regional employed NP program and the vendor driven AWV program Audits the chart review outcomes provided by the risk adjustment vendor and audits provider coding trends to identify potential gaps. Support effective business relationships with external entities, including payers and health plan partners with continuous focus on performance improvement related to population clinical quality and patient experience goals. Requires significant collaboration with internal stakeholders including, but not limited to, primary care section and specialty service lines, IT, business services and finance, contracting, compliance, as well as external entities and vendors will be required Manage regional Provider Incentive and Member Incentive Programs Recover dx codes from institutional encounters through hospitalists/encounters Roll out new regional programs as applicable to improve documentation and accurate coding Ensure the accuracy of risk data in and out of core systems Establish EMR connectivity with Astrana Health and provider group/IPA Ensure compliance with all applicable regulatory and accreditation guidelines such as CMS, NCQA, DMHC etc. Develop policy and procedures as required for departmental improvements. Complete special projects when required. Other duties as assigned Qualifications Bachelor’s Degree Current AAPC or AHIMA certification (CCS, CCS-P, CPC, CPC-H, CPC-P, RHIT, or RHIA) 5 years’ experience of risk adjustment, project management, operations, quality improvement or data analysis/reporting experience in the healthcare industry 5 years’ experience in managerial or supervisory capacity Previous experience in value-based revenue and risk adjustment improvement initiatives Experienced with health plan guidelines/criteria/ICE/CMS/NCQA/DMHC Ability to effectively present information within and outside the organization Advanced ability to manage and work with minimal supervision or absence of detailed instruction. Strong computer skills with proficiency using all Microsoft Office products, and demonstrated ability and willingness to learn new software. Excellent time management, project management, organizational and communication skills. Environmental Job Requirements and Working Conditions This is a remote position. Travel to corporate offices in Orange County, Alhambra, or Monterey Park may be required once a year. The national target pay range for this role is: $102,000 - $115,000. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors. Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation. Additional Information: The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change. 
$145,600 - $237,120 / year
Develops and maintains nursing practice standards of care for a specific transplant population. Serves as a liaison and provides consultation and education services to support standards of care. Identifies and resolves clinical issues relating to the transplant patient. Collaborates with staff, the patient, and his/her family concerning patient evaluation and discharge planning. Maintains appropriate documentation for transplant candidacy and post-transplant follow-up care. Coordinates communications with the outpatient transplant population such as transplant clinic visits, community referrals, telephone consultations, outpatient treatments, and subsequent hospital admissions. Develops and coordinates a system to organize the flow of patients from initial referral, through evaluation and education, to post-transplant follow-up and referral back to the community. Participates in collaborative, interdisciplinary research activities related to transplant patients or process improvement activities. Performs related responsibilities as required. Essential Duties: 1. Independent coordination of outpatient care of the transplant patient by: • Participate in clinic visits and analyze diagnostic tests • Monitor patient and family’s compliance with medical regimen • Review laboratory and other pertinent data, and initiate appropriate action including communication of findings with attending provider • Identify patient care problems and intervene as appropriate 2. Coordinates donor procurement and recipient preparation by • Maintaining waiting list with UNOS • Maintaining communications with transplant team members about the donor and recipient status • Coordinating admission process and preoperative preparation 3. Participates in the development of policies and procedures pertinent to the transplant program. 4. Participates and develops appropriate educational programs, both formal and informal, for the end stage organ disease patient and family, the nursing staff and the medical staff. 5. Serves as a resource person to all staff involved in the care of transplant patients and their families. 6. Appropriately communicates to multidisciplinary team members all identified patient and family problems and assist with appropriate interventions as needed. 7. Responsible for keeping abreast of regulatory Hospital, CMS, OPTN/UNOS policies, and ongoing clinical education in transplant and evidenced based research. 8. Within their scope of practice independently facilitates the evaluation and listing process of the potential transplant patient. Works within the regulatory requirements of CMS and OPTN/UNOS. 9. Maintains communication with referring physicians and insurance case managers. Supplies referring physicians and insurance case managers with necessary information and records. Provides education regarding the transplant evaluation, listing and organ allocation process in order to facilitate patient care. 10. Database management: • Maintains UNOS waiting list • Completes required TIEDI forms • Maintains and manages internal departmental database • Collects and maintains data during of the transplant process as requested 11. Oversees the assignments delegated to support staff, evaluates their performance of given assignments and provides direct supervision in their completion. 12. Functions independently within clinical skills and established processes for patient flow. 13. Works in collaboration with the multidisciplinary transplant team to provide care for the transplant patients across the continuum. 14. Attends the department quality meetings and participates in the department QAPI activities. 15. May be required to be on call 24 hours a day and will participate in a call rotation, which includes relaying information to physician staff and facilitate the ongoing care of the patient as well as handling organ offers. 16. Adheres to all hospital policies including but not limited to attendance, punctuality and dress code 17. Maintains a professional and positive attitude at all time in both patient and office settings 18. Performs other duties as assigned. Required Qualifications: Req Nursing BSN Req 2 years Two years Transplant Coordination experience required and for: • Heart Transplant – two years of cardiology experience • Lung Transplant – two years of pulmonary experience • Liver Transplant – two years of abdominal transplant experience • Kidney / Pancreas Transplant – two years of abdominal transplant experience OR Req 2 years OR: 2 years Organ Procurement experience and 2 years critical care experience required Req Must have excellent communication skills, including the ability to speak, read and write English proficiently. Req Knowledge of medical procedures and conditions and ability to understand, follow and successfully perform duties, including whole blood collection, and apheresis procedures, in accordance with administrative and clinical policies, regulations and procedures. Preferred Qualifications: Pref Nursing Master’s Degree in Nursing or in progress, strongly preferred * Master’s Degree in Nursing may be in lieu-of Bachelor’s Degree in Nursing. Required Licenses/Certifications: Req Registered Nurse - RN (CA Board of Registered Nursing) Active CA RN license Req Basic Life Support (BLS) Healthcare Provider from American Heart Association Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only) The annual base salary range for this position is $145,600.00 - $237,120.00. When extending an offer of employment, the University of Southern California considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, key skills, internal peer equity, federal, state, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations. USC is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, disability, or any other characteristic protected by law or USC policy. USC observes affirmative action obligations consistent with state and federal law. 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