utilization management nurse

Palm Medical Centers

<div>Position Summary: 
The Concurrent Review Nurse is responsible for performing utilization management activities to ensure medical services are delivered effectively, efficiently, and appropriately. This includes reviewing inpatient admissions and ongoing hospital stays to determine medical necessity, appropriateness of care, and length of stay in accordance with clinical guidelines and payer requirements. 
 
Key Responsibilities:<ul><li>
Conduct timely and accurate concurrent reviews of inpatient hospitalizations and other levels of care.</li><li>
Evaluate clinical documentation against evidence-based criteria (e.g., InterQual&reg;, MCG) to determine medical necessity and appropriate level of care.</li><li>
Collaborate with physicians, hospital staff, and insurance companies to coordinate patient care and discharge planning.</li><li>
Communicate utilization review decisions and recommendations to providers and payers.</li><li>
Document all reviews, decisions, and communications in accordance with regulatory and organizational standards.</li><li>
Identify cases requiring escalation or peer review and follow established procedures.</li><li>
Ensure compliance with CMS guidelines, accreditation standards (e.g., NCQA, URAC), and HIPAA.</li><li>
Participate in quality improvement initiatives and departmental meetings</li></ul>
Qualifications: 
 
Education &amp; Licensure:<ul><li>
Registered Nurse (RN) license, active and in good standing, required.</li><li>
Associate or Bachelor&rsquo;s degree in nursing (BSN preferred).</li></ul>
Experience:<ul><li>
Minimum 2 years of clinical experience (e.g., med-surg, critical care).</li><li>
At least 1 year of utilization review, case management, or managed care experience preferred.</li></ul>
Skills &amp; Competencies:<ul><li>
Knowledge of InterQual&reg;, MCG, or other clinical review guidelines.</li><li>
Familiarity with Medicare/Medicaid and commercial insurance regulations.</li><li>
Strong analytical and clinical judgment skills.</li><li>
Effective communication and negotiation skills.</li><li>
Proficient with electronic medical records (EMRs) and utilization review platforms.</li><li>
Detail-oriented with excellent organizational skills.</li></ul>
Work Environment:<ul><li>
Remote</li></ul> 
Palm Primary Care is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws. 
 
This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. Palm Primary Care makes hiring decisions based solely on qualifications, merit, and business needs at the time.
9cbfR8Lziz</div>

Concurrent Review Nurse

Boston Medical Center

<div><div><div><h3 class="jobSectionHeader">Case Manager, Denials and Appeals, 40 Hours (Days)</h3>
 <div></div><div><div><ul><li>46146
</li> </ul></div><div></div><div><ul><li>850 Harrison Avenue, Boston, Massachusetts
</li> </ul></div><div></div><div><ul><li>Full Time</li></ul></div></div><div></div><div><div><div> 
</div></div><div></div><div>
</div></div><div>The UM RN will be responsible for review of potential transfers to the BMC System for tertiary care, in conjunction with the multidisciplinary care team, utilizing medical necessity screening tools to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient&rsquo;s expected length of stay. This nurse secures authorization for the patient&rsquo;s clinical services through timely collaboration and communication with payers as required and follows the UR process, in addition to the pre-denial process as defined in the attached job description and in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review.
POSITION SUMMARY:
Utilizing a collaborative process, the care manager will assess, plan, implement, monitor, and evaluate the options and services required to meet an individual&rsquo;s health needs, using communication and available resources to promote quality, cost-effective outcomes. The care manager helps identify appropriate providers and facilities throughout the continuum of services while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the patient and the reimbursement source. This care manager is dedicated to handle the increased volume and to support the overall care management process and the department.
Position: Case Manager
Department: Denials and Appeals
Schedule: 40 Hours (Days)
JOB REQUIREMENTS
EDUCATION:
Graduate of an accredited BS Program in Nursing
CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:<ul>
<li>
Licensed to practice as a Registered Nurse in the commonwealth of Massachusetts</li>
<li>
CCM or related certification attained within 24 months from the hire date is preferred</li>
</ul>
EXPERIENCE:<ul>
<li>
3-5 years of diversified clinical experience is required</li>
<li>
A minimum of 2 years of previous experience involving judgment and decision making, preferably in a utilization management/case management position</li>
</ul>
KNOWLEDGE AND SKILLS:<ul>
<li>
Extensive background and knowledge of current medical/surgical patterns of practice.</li>
<li>
Medical terminology and standard medical abbreviations.</li>
<li>
Managed care concepts, the various health care delivery systems</li>
<li>
Methods for assessing an individual are level of physical/mental impairment, understanding of the physical and psychological characteristics of illness, and understanding of expected treatment.</li>
<li>
Confidentiality issues and the legal and ethical issues pertaining to them.</li>
<li>
ICD-9 and CPT nomenclature and the ability to interpret and convert this information, as applicable.</li>
<li>
Knowledge of benefits and various plan contracts, eligibility issues and requirements.</li>
<li>
Role and functional responsibilities of case management professional; case management program philosophy and purpose within Managed Care Program</li>
<li>
Excellent interpersonal, verbal and written communication and negotiations skills</li>
<li>
Strong analytical, data management and PC skills</li>
</ul><h3 class="jobSectionHeader">
NursingCM</h3>
Compensation Range:
$38.05- $75.33
This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, and licensure/certifications directly related to position requirements. In addition, BMCHS offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), contract increases, Flexible Spending Accounts, 403(b) savings matches, earned time cash out, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.
Equal Opportunity Employer/Disabled/Veterans
According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website. We do not ask or require downloads of any applications, or &ldquo;apps&rdquo; job offers are not extended over text messages or social media platforms. We do not ask individuals to purchase equipment for or prior to employment.</div></div></div></div>

Case Manager, Denials and Appeals, 40 Hours (Days)

HMSA

<div>
 
 Employment Type
 
 
 
 Full-time
 
 
 
 Exempt or Non-Exempt
 
 
 
 Exempt
 
 
 
 Job Summary
 
 
 
 
 Hybrid Work Environment - Must reside in Hawaii
 
 
 
 
 Pay Range:
 
 $59,000 to $116,000
 
 
 
 Note
 
 : Individuals typically begin between the minimum to middle of the pay range
 
 
 Under minimal supervision, conducts detailed analysis and review of precertification requests, post-service and suspended claims, by applying clinical expertise against HMSA medical and reimbursement policies, plan benefits and nationally accepted clinical guidelines to determine appropriateness of care for all HMSA lines of business.
 
 
 
 Minimum Qualifications
 
 
 
 <ul>
 <li>
 Associates degree in Nursing.
 </li>
 <li>
 Current, unrestricted Nursing License in the state of Hawaii as an RN or LPN.
 </li>
 <li>
 Two years clinical, case management or utilization management related experience.
 </li>
 <li>
 Knowledge of current standards of care to be followed for a given diagnosis and the normative values of medical tests and procedures.
 </li>
 <li>
 Strong organizational skills
 </li>
 <li>
 Good communication skills both verbally and written
 </li>
 <li>
 Analytical skills
 </li>
 <li>
 Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, and Outlook.
 </li>
 <li>
 Currently licensed in Hawaii as an RN or LPN
 </li>
 <ul>
 <li>
 (if applicable upon hire, proof of licensure to be provided by employee or confirmed by Human Resources)
 
 </li>
 </ul>
 </ul>
 
 Duties And Responsibilities
 
 
 
 <ul>
 <li>
 Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
 </li>
 <ul>
 <li>
 Demonstrate understanding and application of over 250 Guide to Benefits, Evidence of Coverage, Plan Brochure, and Member Handbook. HMSA annually updated medical and drug policies, medical protocols, National Comprehensive Cancer Network, Milliman Care Guidelines, Drugdex, etc. to determine the medical necessity of urgent and non-urgent precertification requests. Urgent requests must be completed within 72 hours and non-urgent requests within 15 calendar days.
 </li>
 <li>
 Use clinical judgment, medical necessity guidelines and plan benefits to determine approval, potential denial or alternative treatment of each urgent or non-urgent precertification request. Settings include inpatient, outpatient, in-state, out-of state and out-of country.
 </li>
 <li>
 Document clinical case summary and review outcome of each review appropriately to meet regulatory and program requirements.
 </li>
 <li>
 Review various types of services, including but not limited to:
 </li>
 <li>
 Transplants
 </li>
 <li>
 Air Ambulance
 </li>
 <li>
 Chemotherapy
 </li>
 <li>
 Clinical trials
 </li>
 <li>
 Genetic testing
 </li>
 <li>
 Cancer treatments/radiation therapy
 </li>
 <li>
 Experimental/Investigational Services/Devices
 </li>
 <li>
 New Technology
 </li>
 </ul>
 <li>
 Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
 </li>
 <ul>
 <li>
 Call providers when additional clinical information is required to clarify or complete a complex precertification determination.
 </li>
 <li>
 Approve precertification requests based on clinical judgment using criteria, medical record documentation and other information received from the provider.
 </li>
 <li>
 Consult with Medical Directors on requests which do not meet clinical criteria and offer alternative covered health care options as appropriate.
 </li>
 <li>
 Consult Medical Directors on potential quality issues identified during review of medical records. Refer cases to Integrated Health Management, Pharmacy Department or Benefits Integrity Department depending on the concern.
 </li>
 </ul>
 <li>
 Evaluate suspended claims against medical records to determine the medical necessity and appropriateness of medical services, identify irregularities such as over or under-utilization of services, potential up-coding, over billing, etc.
 </li>
 <li>
 Communicate timely, accurate information either verbally, electronically or in writing using clinical judgment, knowledge of medical/reimbursement policies and plan benefits to providers, members as well as internal MM staff and other internal departments (Claims Administration, Customer Relations, Provider Contracting, etc.). For denied services, ensure the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation and regulatory guidelines.
 </li>
 <li>
 Identify and refer members with specific medical and/or behavioral health needs or complex case management and collaborate with medical and behavioral case management staff. Identify and refer quality of care issues and suspected fraud, waste or abuse to the appropriate departments.
 </li>
 <li>
 Perform pre-screening assessment of incoming pre-certification requests to ensure appropriateness of review. Advises non-clinical staff on clinical and coding questions to ensure correct system processes and entries.
 </li>
 <li>
 Performs all other miscellaneous responsibilities and duties as assigned or directed.
 
 
 </li>
 </ul>
</div>

Nurse Reviewer - Clinical Review Unit

Highmark Health

<div><h2 class="jobSectionHeader">Company :
</h2>Highmark Inc.
<h2 class="jobSectionHeader">Job Description :
</h2>JOB SUMMARY
This job implements effective utilization management strategies including: review of appropriateness of health care services, application of criteria to ensure appropriate resource utilization, identification of opportunities for referral to a Health Coach/case management, and identification and resolution of quality issues. Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction. Responds to customer inquiries and offers interventions and/or alternatives.
ESSENTIAL RESPONSIBILITIES
<ul><li>Implement care management review processes that are consistent with established industry and corporate standards and are within the care manager&rsquo;s professional discipline.
</li><li>Function in accordance with applicable state, federal laws and regulatory compliance.
</li><li>Implement all care management reviews according to accepted and established criteria, as well as other approved guidelines and medical policies.
</li><li>Promote quality and efficiency in the delivery of care management services.
</li><li>Respect the member&rsquo;s right to privacy, sharing only information relevant to the member&rsquo;s care and within the framework of applicable laws.
</li><li>Practice within the scope of ethical principles.
</li><li>Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions.
</li><li>Employ collaborative interventions which focus, facilitate, and maximize the member&rsquo;s health care outcomes. Is familiar with the various care options and provider resources available to the member.
</li><li>Educate professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and relationships.
</li><li>Develop and sustain positive working relationships with internal and external customers.
</li><li>Utilize outcomes data to improve ongoing care management services.
</li><li>Other duties as assigned or requested
</li></ul>EDUCATION
Required
<ul><li>None
</li></ul>Substitutions
<ul><li>None
</li></ul>Preferred
<ul><li>Bachelor&rsquo;s Degree in Nursing
</li></ul>EXPERIENCE
Required
<ul><li>3 years of related, progressive clinical experience in the area of specialization
</li><li>Experience in a clinical setting
</li></ul>Preferred
<ul><li>Experience in UM/CM/QA/Managed Care
</li></ul>LICENSES AND CERTIFICATIONS
Required
<ul><li>Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). Additional specific state licensure(s) may be required depending on where clinical care is being provided.
</li></ul>Preferred
<ul><li>Certification in utilization management or a related field
</li></ul>SKILLS
<ul><li>Working knowledge of pertinent regulatory and compliance guidelines and medical policies
</li><li>Ability to multi task and perform in a fast paced and often intense environment
</li><li>Excellent written and verbal communication skills
</li><li>Ability to analyze data, measure outcomes, and develop action plans
</li><li>Be enthusiastic, innovative, and flexible
</li><li>Be a team player who possesses strong analytical and organizational skills
</li><li>Demonstrated ability to prioritize work demands and meet deadlines
</li><li>Excellent computer and software knowledge and skills
</li></ul>Languages (Other than English)
None 
 
Travel Requirement
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office-Based
Teaches/trains others regularly
Occasionally
Travel regularly from the office to various work sites or from site-to-site
Does Not Apply
Works primarily out-of-the office selling products/services (sales employees)
Does Not Apply
Physical work site required
Yes
Lifting: up to 10 pounds
Constantly
Lifting: 10 to 25 pounds
Occasionally
Lifting: 25 to 50 pounds
Rarely, Occasionally
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company&rsquo;s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee&rsquo;s responsibility to comply with the company&rsquo;s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum:
$68,400.00
Pay Range Maximum:
$105,900.00
Base pay is determined by a variety of factors including a candidate&rsquo;s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.
For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org
California Consumer Privacy Act Employees, Contractors, and Applicants Notice</div>

Care Manager RN (Remote)

Centene

<div>You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. 
Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member.<ul><li>
Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care</li>
<li>Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member</li>
<li>Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered</li>
<li>Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines</li>
<li>Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings</li>
<li>Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members</li>
<li>Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines</li>
<li>Reviews member&rsquo;s transfer or discharge plans to ensure a timely discharge between levels of care and facilities</li>
<li>Collaborates with care management on referral of members as appropriate</li><li>
Performs other duties as assigned.</li>
<li>Complies with all policies and standards.</li></ul>
We are seeking a Clinical Review Nurse - Concurrent Review to join our team!
The ideal candidate will bring expertise in:
IL Nursing License
 
Concurrent Review
 
Inpatient Authorizations 
Discharge Planning 
Acute and/or Critical Care
 
Computer Savvy
 
Excellent Customer Service and Communication Skills
Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor&rsquo;s degree in Nursing and 2 &ndash; 4 years of related experience. 2+ years of acute care experience required. 
 
Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. 
Knowledge of Medicare and Medicaid regulations preferred. 
Knowledge of utilization management processes preferred. 
 
License/Certification:<ul><li>
LPN - Licensed Practical Nurse - State Licensure required</li></ul>
Pay Range: $27.02 - $48.55 per hour
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. 
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act</div>

Clinical Review Nurse - Concurrent Review

Valley Medical Center

<div></div><div><div><div><ul><li><h6 class="jobSectionHeader">Job Title:</h6>
 Clinical Documentation Specialist
</li><li><h6 class="jobSectionHeader">Req:</h6>
 2026-0293
</li><li><h6 class="jobSectionHeader">Location:</h6>
 VMC Main Campus
</li><li><h6 class="jobSectionHeader">Department:</h6>
 Health Information Mgmt
</li><li><h6 class="jobSectionHeader">Shift:</h6>
 Days
</li><li><h6 class="jobSectionHeader">Type:</h6>
 Full Time
</li><li><h6 class="jobSectionHeader">FTE:</h6>
 1
</li><li><h6 class="jobSectionHeader">Hours:</h6>
</li><li><h6 class="jobSectionHeader">City State:</h6>
 Renton, WA
</li><li><h6 class="jobSectionHeader">Salary Range:</h6>
 Min $94,894 - Max $142,341/annual DOE</li></ul></div></div> 
 
 
 
Job Description:
VALLEY MEDICAL CENTER

JOB DESCRIPTION

The position description is a guide to the critical duties and essential functions of the job, not an all-inclusive list of responsibilities, qualifications, physical demands, and work environment conditions. Position descriptions are reviewed and revised to meet the changing needs of the organization.

TITLE: Clinical Documentation Specialist RN

JOB OVERVIEW: The Clinical Documentation Specialist position facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the documentation improvement process is a key role.

DEPARTMENT: Health Information Management

HOURS OF WORK: Days Monday - Friday.

RESPONSIBLE TO: Manager, Clinical Documentation Improvement

PREREQUISITES:
<div>
<ul><li>Current unrestricted WA State Registered Nurse license, required.
</li></ul>
<ul><li>Bachelor's degree in Nursing, preferred.
</li></ul>
<ul><li>Minimum five years recent clinical experience as an RN working in an acute care setting or with experience in Utilization Review
</li></ul>
<ul><li>Pass a pre-hire Clinical Exam with a minimum score of 70%
</li></ul>
<ul><li>Effective communication with Providers
</li></ul>
</div>QUALIFICATIONS:
<div>
<ul><li>Knowledge of hospital clinical practice standards for physicians and other health care providers.
</li></ul>
<ul><li>Knowledge of ancillary service departments, quality control and safety standards.
</li></ul>
<ul><li>Critical thinking, problem solving and deductive reasoning skills.
</li></ul>
<ul><li>Familiarity with health care audit and research design.
</li></ul>
<ul><li>Knowledge of Pathophysiology and Disease process.
</li></ul>
<ul><li>Functional knowledge of DRG coding systems.
</li></ul>
<ul><li>Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.
</li></ul>
<ul><li>Knowledge of third-party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.
</li></ul>
<ul><li>Meet productivity guidelines.
</li></ul>
<ul><li>Ability to learn/develop the skills necessary to perform and meet goal standards
</li></ul>
<ul><li>Organizational, analytical, writing, and interpersonal skills
</li></ul>
<ul><li>Dependable, self-directed, and pleasant
</li></ul>
<ul><li>Critical thinking, problem solving and deductive reasoning skills
</li></ul>
<ul><li>Knowledge of Pathophysiology and Disease Process
</li></ul>
<ul><li>Basic Computer skills - familiarity with Windows based software programs
</li></ul>
<ul><li>Knowledge of regulatory environment
</li></ul>
<ul><li>Understand and support documentation strategies (upon completion of training)
</li></ul>
<ul><li>Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)
</li></ul>
</div>UNIQUE PHYSICAL/MENTAL DEMANDS, ENVIRONMENT AND WORKING CONDITIONS:

See Generic Job Description for Administrative Partner.

PERFORMANCE RESPONSIBILITIES:

A. Generic Job Functions: See Generic Job Description for Administrative Partner.

B. Essential Responsibilities and Competencies
<div>
<ul><li>Reviews EMR for completeness and accuracy for severity of illness and quality using the documentation strategies.
</li></ul>
<ul><li>Accurate and timely record review.
</li></ul>
<ul><li>Recognize opportunities for documentation improvement.
</li></ul>
<ul><li>Initiates severity worksheet for inpatients.
</li></ul>
<ul><li>Formulate clinically credible documentation clarifications.
</li></ul>
<ul><li>Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety.
</li></ul>
<ul><li>Effective and appropriate communication with physicians.
</li></ul>
<ul><li>Timely follow up on all cases and resolution of those with clinical documentation clarifications.
</li></ul>
<ul><li>Communicates with HIM staff and resolves discrepancies.
</li></ul>
<ul><li>Accurate input of data for reconciliation of case.
</li></ul>
<ul><li>Provide necessary information and education to physicians and staff to facilitate the appropriate documentation goals.
</li></ul>
<ul><li>Identify any barriers to completion of documentation goals with appropriate interventions.
</li></ul>
<ul><li>Review of regulations and coding guidelines through seminars, meetings, and materials.
</li></ul>
<ul><li>In cooperation with the director of PFS/HIM, present education sessions to physicians and other VMC providers regarding documentation regulations and chart audit findings.
</li></ul>
<ul><li>Maintains confidentiality of all accessible patient financial or medical records information.
</li></ul>
<ul><li>Demonstrates the awareness of the importance of cost containment for the department. Provide suggestions regarding process or quality improvement opportunities to department manager.
</li></ul>
<ul><li>Other duties as assigned to facilitate accurate, timely patient account management.
</li></ul>
</div>Date Created: 5/18, updated 7/22

Grade: NC11

FLSA: E

Cost Center: 8490 

Job Qualifications:
PREREQUISITES:
<div>
<ul><li>Current unrestricted WA State Registered Nurse license, required.
</li></ul>
<ul><li>Bachelor's degree in Nursing, preferred.
</li></ul>
<ul><li>Minimum five years recent clinical experience as an RN working in an acute care setting or with experience in Utilization Review
</li></ul>
<ul><li>Pass a pre-hire Clinical Exam with a minimum score of 70%
</li></ul>
<ul><li>Effective communication with Providers
</li></ul>
</div>QUALIFICATIONS:
<div>
<ul><li>Knowledge of hospital clinical practice standards for physicians and other health care providers.
</li></ul>
<ul><li>Knowledge of ancillary service departments, quality control and safety standards.
</li></ul>
<ul><li>Critical thinking, problem solving and deductive reasoning skills.
</li></ul>
<ul><li>Familiarity with health care audit and research design.
</li></ul>
<ul><li>Knowledge of Pathophysiology and Disease process.
</li></ul>
<ul><li>Functional knowledge of DRG coding systems.
</li></ul>
<ul><li>Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.
</li></ul>
<ul><li>Knowledge of third-party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.
</li></ul>
<ul><li>Meet productivity guidelines.
</li></ul>
<ul><li>Ability to learn/develop the skills necessary to perform and meet goal standards
</li></ul>
<ul><li>Organizational, analytical, writing, and interpersonal skills
</li></ul>
<ul><li>Dependable, self-directed, and pleasant
</li></ul>
<ul><li>Critical thinking, problem solving and deductive reasoning skills
</li></ul>
<ul><li>Knowledge of Pathophysiology and Disease Process
</li></ul>
<ul><li>Basic Computer skills - familiarity with Windows based software programs
</li></ul>
<ul><li>Knowledge of regulatory environment
</li></ul>
<ul><li>Understand and support documentation strategies (upon completion of training)
</li></ul>
<ul><li>Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)</li></ul></div></div>

Clinical Documentation Specialist

Gila River Health Care

<div>Summary :
The Case Manager will provide comprehensive Case Management for patients as assigned to include, but not limited to: assessing patient&rsquo;s needs; developing, implementing, monitoring, and documenting the progress of the patient throughout their hospitalization in an outside area hospital to meet their care needs prior to discharge. The intensity of Case Management is situational and appropriately based on patient need. This position is accountable for the quality of clinical services provided by both them and others and identifies barriers which may hinder effective patient care. The Case Manager performs Utilization Review of the medical necessity and appropriateness of care using InterQual criteria of patients admitted to Gila River Health Care inpatient unit: assessing patient admissions and continued stay criteria to identify issues that may delay patient discharge and facilitate resolution of these issues. 
 
Critical Tasks:
<ul><li>Demonstrates a culture of kindness through all interactions whether verbal or non-verbal with all GRHC staff members, partner facilities staff and vendors.
</li></ul><ul><li>Manages and oversees assigned patient case load to ensure delivery of all covered services identified for continuity of care across all levels of care and involved providers to achieve the optimal clinical, financial, operational, and patient satisfaction outcomes.
</li></ul><ul><li>Maintains HIPAA standards of patient confidentiality during all interactions whether written, verbal, or electronic.
</li></ul><ul><li>Establishes and promotes a collaborative relationship with members of the healthcare team within GRHC and outside facility partners.
</li></ul><ul><li>Serves as Case Manager between referral hospitals, treatment facilities and patients/patient&rsquo;s families to ensure delivery of effective and appropriate assistance and follow-up for returning to pre/post hospitalization status/care.
</li></ul><ul><li>Reviews charts of assigned patients to determine appropriate referral services based on assessed patient needs.
</li></ul><ul><li>Facilitates, schedules and/or participates in a variety of patient Case Management activities to ensure patient and/or family personal and health care needs are met in a timely manner; proactively identifies alternative resources as needed.
</li></ul><ul><li>Participates in &ldquo;on-call&rdquo; for Case Management Department and Utilization Review
</li></ul><ul><li>Performs Utilization Review of patient chart to ensure compliance with established InterQual criteria to maximize reimbursement/coverage of charges.
</li></ul><ul><li>Evaluates inpatient medical necessity and appropriateness of care utilizing InterQual criteria, for optimizing outcomes.
</li></ul><ul><li>Assesses patient admissions and continued stay to identify issues that may delay patient discharge and communicates to the interdisciplinary team while facilitating a resolution.
</li></ul><ul><li>Collects and communicates pertinent, timely information to the health care team to fulfill utilization and regulatory requirements.
</li></ul><ul><li>Collaborates with patient, family members, and other involved parties to ensure care coverage through private and governmental health care plans.
</li></ul><ul><li>Collects outcome data to be used in identifying best practices and targeting performance improvement solutions.
</li></ul><ul><li>Participates in departmental orientation, on the job training, and quality assurance programs/initiatives.
</li></ul><ul><li>Receives and responds to patient concerns; research issues for corrective action as appropriate based on findings; escalates physician/provider concerns to appropriate parties and identifies alternative solutions.
</li></ul><ul><li>Participates in a variety of department and hospital educational programs to maintain current skill and competency levels; identifies and discusses performance or training needs with Supervisor.
</li></ul><ul><li>Participates in Community Events representing GRHC and Case Management Department with ability to educate on departmental functions.
</li></ul><ul><li>Other duties as assigned by Case Management Director/Manager
</li></ul><ul><li>Establishes goals and objectives for the department that meet or exceed GRHC&rsquo;s Code of Ethics and Standards for Conduct Policy.
</li></ul><ul><li>Is familiar and remains current on safety and emergency management process for the department.
</li></ul>Required Qualifications:
<ul><li>Current State of Arizona or Compact State Registered Nurse license, BSN preferred.
</li></ul><ul><li>Current CPR for Healthcare professional's certification
</li></ul><ul><li>Must have at least 1-year previous case management experience, CCM certification preferred but must obtain within 2 years of hire.
</li></ul><ul><li>Experience must include working in an acute care and/or home care setting for at least a 12-month period.
</li></ul><ul><li>Native American population preferred.
</li></ul><ul><li>Must have a working knowledge of Case Management, acute care and/or home care environments, community resources and resource/utilization management.
</li></ul><ul><li>Case Management Specialty Area Requirements :
<ul><li>Pediatrics Case Manager &ndash; Must have at least 1 year Pediatrics experience
</li><li>Cancer Case Manager &ndash; Must have at least 1 year oncology/hospice/or cancer case management experience
</li><li>Pain Management Case Manager &ndash; Must have at least 1 year experience working with pain management patients/hospice patients .
</li><li>Women&rsquo;s Health/High Risk Pregnancy Case Manager &ndash; Must have at least 1 year Women&rsquo;s Health/Pregnancy experience
</li><li>Family Medicine Case Manager &ndash; Must have at least 1 year Medical-Surgical or Family Clinic experience
</li><li>Internal Medicine Case Manager - Must have at least 1 year Medical-Surgical or Family Clinic experience
</li><li>Emergency Department/Utilization Review Case Manager &ndash; Must have 1 year Medical-Surgical experience and/or 1 year Utilization Review experience</li></ul></li></ul></div>

Case Manager-Case Management-HHK-Sacaton

Search 10000+ Utilization management nurse jobs near you this June. New roles added regularly across leading industries. Apply today.