Overview
The Post Acute Clinical Review Registered Nurse (RN) is responsible for clinically reviewing, managing and coordinating referrals to post-acute care, ensuring completeness and accuracy to support medical necessity. This role ensures timely access for admission to the Skilled Nursing Facilities (SNF) or appropriate healthcare facilities and/or services. The RN utilizes clinical knowledge, experience, and assessment of clinical documentation for medical necessity review. The RN serves as a key clinical liaison among providers, patients, SNF partners and internal stakeholders to support safe transitions to post acute services and continuity of care.
Responsibilities
JOB FUNCTIONS:
Essential Functions:
- Conduct clinical review of incoming post-acute care referrals to ensure completeness and accuracy of documentation to support medical necessity for short term SNF placement or other post-acute care services.
- Thorough review of eligibility to ensure active enrollment in health coverage.
- Determine whether referrals meet established clinical and programmatic criteria with loop closure communication for referrals that do not meet criteria to referral source.
- Manage referral workflows to support timely decision making, prioritization, and throughout.
- Provide clear status updates to internal teams, providers, and external partners.
- Identify clinically complex, high-risk, or unclear cases and escalate to internal providers for further review and determination.
- Utilize nursing knowledge and clinical judgment to assess referral urgency and complexity to prioritize accordingly for timely placement.
- Conduct a thorough review of inpatient hospital records to verify clinical documentation meets medical necessity criteria for post-acute placement.
- Collaborate with inpatient care teams, case management, and providers to clarify referral needs and/or clinical documentation.
- Serve as the initial RN to review referral escalations to providers to support clinical analysis and determining appropriateness for SNF placement.
- Serve as a clinical liaison between providers, hospital case management teams, post-acute care facilities and other external partners.
- Monitor and track referral progress and proactively follow up to ensure seamless continuity of patient care and avoid unnecessary delays.
- Identify, assess and address barriers to referral progression including but not limited to patients’ SNF location preferences, SNF admission guidelines, medical power of attorney (MPOA) considerations, and discharge medications.
- Communicates with Skilled Nursing Facility liaison and admissions teams to facilitate clinical acceptance, bed placement and coordination of patient arrival.
- Collaborates with Utilization Management department to optimize resource allocation.
- Serve as primary liaison with durable medical equipment (DME) vendors ensuring required equipment is delivered prior to patients’ arrival at the skilled nursing facility.
- Attends staff meetings, huddles, and education offerings (in person and virtual) to maintain role competency and department alignment.
- Supports organizational and departmental initiatives to promote and maintain a collaborative and positive workplace culture.
- Maintain accurate, timely, and appropriate documentation of referral reviews, determinations, and care coordination activities in the electronic health record system.
- Adhere to HIPAA compliance, organizational policies and regulatory standards.
- Awareness of department performance indicators, metrics, and quality measures.
- Performs other duties as assigned.
Knowledge, Skills and Abilities:
- Knowledge and proficiency in the practice of nursing and documentation requirements.
- Knowledge of post-acute care settings and services including skilled nursing facilities and other postacute care settings.
- Knowledge of medical necessity and utilization review concepts and documentation standards.
- Ability to work with medical and nursing staff to establish and maintain clinical and operational standards of practice.
- Ability to work in a highly collaborative manner with patients and other internal or external service providers.
- Knowledge of electronic health record systems and clinical documentation workflows.
- Ability to deliver high‑quality customer service through telephone, electronic, and in‑person communication.
- Strong problem‑solving skills to identify and address barriers to better serve patients and staff
- Proficiency in applying Microsoft Office software tools in a system environment.
- Strong attention to detail and accuracy.
- Strong assessment, critical thinking and effective decision-making skills.
- Knowledge of complex medical conditions and co morbidities.
- Ability to apply independent nursing judgment in reviewing referrals, assessing medical necessity, and determining appropriateness.
- Ability to thrive in a complex and dynamic work environment with multidisciplinary, cross-functional teams and matrixed team structures.
- Knowledge of social determinants of health issues and demonstrate cultural humility and sensitivity when work with underserved patient populations.
- Skill in triaging and ensuring appropriate level of care for patients.
- Ability to maintain professionalism, confidentiality, and ethical standards in all interactions.
Qualifications
QUALIFICATIONS:
Education:
Associates Degree (higher degree accepted) Graduation from an accredited school of nursing with an Associate Degree in Nursing (ADN) -Required
Work Experience:
Minimum of 2 years of clinical nursing experience (preferably acute care, ambulatory or case management) -Required
Licenses and Certifications:
Registerd Nurse (RN) - State Licensure and/or Compact State License Current unrestricted RN license to practice nursing in the State of Texas -Upon Hire Required
BLS - Basic Life Support Basic Life Support (BLS) - Obtained through approved American Heart Association Training Network or American Red Cross -Upon Hire Required
Driver's License - Valid Driver's License -Upon Hire Required
