utilization management nurse lead

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.
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Concurrent Review Nurse

Stanford Health Care

<div>0.2 FTE Part time Day - 08 Hour R2654519 Onsite 108751001 Case Management Inpatient Nursing PALO ALTO, 300 Pasteur Dr, California
If you're ready to be part of our legacy of hope and innovation, we encourage you to take the first step and explore our current job openings. Your best is waiting to be discovered. 

Day - 08 Hour (United States of America)
This is a Stanford Health Care job. 
 
A Brief Overview 
Case Managers are licensed nursing professionals responsible for coordinating continuum of care and discharge planning activities for a caseload of assigned patients. Major responsibilities include coordinating all facets of a patient's admission/discharge; performing utilization review activities, including review of patient charts for timeliness of services as well as appropriate utilization of services; and ensuring optimum use of resources, service delivery, and compliance with external review agencies' requirements. Case Managers act as consultants to the clinical team, service lines, and other departments regarding patient assessment and patient care and participate in program development and quality improvement initiatives. In their role. Case Managers, by applying guidelines and collaborating with multidisciplinary teams, influence and direct the delivery and quality of patient care. A hospital-based case management system has as its primary goal to ensure the most appropriate use of services by patients and. toward that end, to avoid duplication and misuse of medical services, control costs by reducing inefficient services, and improve the effectiveness of care delivery. Objectives are to facilitate timely discharge: prompt, efficient use of resources; achievement of expected outcomes; collaborative practice; coordination of care across the continuum; and performance/quality improvement activities that lead to optimal patient outcomes. A Case Manager differs from other roles in professional nursing/health care practice in that it is not intended to provide direct patient care; rather, a Case Manager will be assigned to specific patients to ensure that the medical services and treatments required are accomplished in the most financially and clinically efficient manner. This job description covers all classifications for Case Managers within the organization. All Case Managers must meet all elements of the Essential Functions, and Qualifications. 
 
Locations 
Stanford Health Care 
 
What you will do<ul><li>
Coordination of Care &mdash; Complex case manager who manages each patient's transition through the system and transfers accountability to the appropriate person upon entry into another clinical service or discharge.</li><li>
Discharge Planning - - Coordinates and facilitates timely implementation of discharge plans for assigned patients with complex needs in collaboration with other interdisciplinary team members; arranges follow up care as appropriate.</li><li>
Utilization Review &ndash; Review prospectively, concurrently and retrospectively, all inpatients for appropriateness of admission, level of care, and determines appropriate length to stay. Monitors patients' length of stay and collaborates with physicians to ensure resource utilization remains within covered benefits and are appropriate in relationship to the patient's clinical and psychosocial needs; plans and implements (through multi-disciplinary meetings or rounds) strategies to reduce length of stay, reduce resource consumption, and achieve positive patient outcomes, analyzes and addresses aggregate variances as well as variances for individual patients and shares this information with staff, physicians, and administration.</li><li>
Education/Consultation- Acts as an educational resource and provides consultation to patients and their families, hospital medical personnel regarding the discharge planning process and applicable regulatory requirements; educates the staff on case management; and provides specific information related to case types.</li><li>
Lead Work- May lead the work of administrative/clinical support staff responsible for assisting with case management for an assigned patient caseload. Other - Participates in department program planning, goal setting, systems development and process improvement; participates in department and hospital committees and task forces; develops and maintains documentation of findings, discharge arrangements, and actions taken according to departmental guidelines; prepares and maintains records as required; collects, analyzes and reports on data for utilization, quality improvement, compliance, and other areas as assigned.</li><li>
Patient Assessment / Plan of Care- Functions as a resource to and collaborates with physicians, social workers, nurses, and other interdisciplinary team members to assess, plan, and coordinate patient care needs and/or performs patient assessment and develops a plan of care to assure consistent, timely, and appropriate care is provided in a patient focused manner.</li>
Quality Improvement <li>- Participates in quality improvement activities by identifying opportunities for improvement in such areas as clinical outcomes, utilization of resources and concurrent data collection; participates in clinical process improvement teams within the department, service lines, and hospital.</li>
Third-Party Reimbursement <li>- Collects, analyzes reports and reviews patient information with third-party payers to assure reimbursement for patient services/procedures. Communicates with review organizations / payers to provide requested clinical and psychosocial information to assure reimbursement.</li></ul> 
Education Qualifications<ul><li>
Bachelor's Degree from an accredited college or university required</li><li>
Master's Degree preferred</li></ul> 
Experience Qualifications<ul><li>
Three (3) years of progressively responsible and directly related work experience required</li></ul> 
Required Knowledge, Skills and Abilities<ul><li>
Ability to collect and record data, evaluate data and statistics, and maintain effective reporting systems</li><li>
Ability to develop and perform patient assessment and plan of care</li><li>
Ability to monitor and assure the patient's access to the appropriate level of care; the right health care providers; and the correct setting and services to meet the patient's needs; promote coordination and continuity in patient health care</li><li>
Ability to provide age-appropriate assessments, interpretation of data, and delivery of interventions</li><li>
Ability to provide appropriate patient care and clinical information when patients are admitted, referred, transferred, or discharged</li><li>
Ability to remain knowledgeable regarding available treatments and services</li><li>
Ability to resolve conflicts and/or negotiate with others to achieve positive results; establish and maintain effective interpersonal relationships</li><li>
Ability to understand, interpret and apply complex federal and state hospital compliance laws, rules, regulations and guidelines</li><li>
Ability to work effectively with individuals at all levels of the organization</li><li>
Knowledge of available patient services and treatment</li><li>
Knowledge of current theories, principles, practices, standards, emerging technologies, techniques and approaches in the nursing profession, and the health care system, and the responsibility and accountability for the outcome of practice</li><li>
Knowledge of evaluation and assessment techniques</li><li>
Knowledge of financial processes of various private and public funding sources for health care services/procedures</li><li>
Knowledge of hospital operations, organization, systems and procedures and laws and regulations pertaining to the operation of hospitals in California</li><li>
Knowledge of medical terminology and related levels of care and treatment</li><li>
Knowledge of the full continuum of care available to patents, interrelationships of the care components, and their effective integration</li><li>
Knowledge of the models of case management, including the principles and practices of discharge planning, utilization review, and quality assurance/improvement</li><li>
Knowledge of the variables that affect the processes and outcomes of patient health care</li></ul> 
Licenses and Certifications<ul><li>
CA-RN (Registered Nurse) required</li></ul> 
These principles apply to ALL employees: 
 
SHC Commitment to Providing an Exceptional Patient &amp; Family Experience 
 
Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford&rsquo;s patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery. 
 
You will do this by executing against our three experience pillars, from the patient and family&rsquo;s perspective:
<ul><li>Know Me: Anticipate my needs and status to deliver effective care</li><li>
Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health</li><li>
Coordinate for Me: Own the complexity of my care through coordination</li></ul>
Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.
Base Pay Scale: Generally starting at $111.35 - $126.14 per hour
The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.</div>

Case Manager (RN) - Inpatient - Relief A Status (0.2 FTE), 08-HR, Day Shift

White Oak Management, Inc.

Overview Join our dynamic healthcare team as an Assistant Director of Nursing / MDS Coordinator, where you will play a pivotal role in ensuring exceptional patient care and compliance with regulatory standards. This energetic position offers the opportunity to lead clinical documentation improvement initiatives, coordinate comprehensive assessments, and oversee medical records management within a fast-paced, multidisciplinary environment. Your expertise will directly impact patient outcomes, operational efficiency, and adherence to industry standards such as NCQA and HIPAA. If you thrive in a collaborative setting and possess a passion for nursing excellence and healthcare management, this role is your next career milestone!Duties<ul><li>This is an on-call role features an on-call rotation schedule.</li><li>Lead the development and implementation of the Minimum Data Set (MDS) assessments to ensure accurate and timely completion in compliance with federal regulations.</li><li>Coordinate interdisciplinary team efforts to optimize patient care planning, discharge planning, and clinical documentation improvement.</li><li>Oversee medical records management, ensuring accuracy, completeness, and confidentiality in accordance with HIPAA standards.</li><li>Utilize advanced EMR (Electronic Medical Record) systems such as Ecin, Epic, or PCC to review medical documentation, coding, and clinical data.</li><li>Conduct utilization review and utilization management activities to support appropriate resource allocation and reimbursement processes including Medicare and managed care programs.</li><li>Collaborate with nursing staff on CPT coding, ICD-9/10 coding, DRG assignment, and medical documentation review to enhance coding accuracy and reimbursement.</li><li>Facilitate training sessions on healthcare regulations, ICD coding updates, and documentation best practices for clinical staff.</li><li>Assist in case management activities like discharge planning for hospice care or outpatient services to ensure seamless patient transitions across care settings.</li></ul>Experience<ul><li>Proven experience in nursing leadership roles with a focus on MDS coordination or clinical documentation improvement within long-term care facilities or hospitals.</li><li>Extensive knowledge of Epic EMR systems used for medical records management.</li><li>Demonstrated expertise in ICD-10/ICD-9 coding, CPT coding, DRG assignment, and Medicare regulations related to inpatient and outpatient billing processes.</li><li>Strong background in managed care environments with familiarity in utilization review and utilization management processes.</li><li>Critical care experience preferred along with nursing home experience or hospital-based acute care exposure.</li><li>Familiarity with healthcare quality standards such as NCQA standards; experience supporting clinical documentation improvement initiatives is highly desirable.</li><li>Knowledge of physiology, anatomy, medical terminology, HIPAA compliance requirements, and health information management practices essential for success.</li><li>Excellent communication skills combined with the ability to train multidisciplinary teams on complex documentation procedures while maintaining a lively enthusiasm for continuous improvement. Embark on a rewarding career journey where your leadership enhances patient outcomes through meticulous documentation and innovative healthcare solutions!</li></ul>Pay: Up to $45.00 per hourBenefits:<ul><li>Dental insurance</li><li>Health insurance</li><li>Paid time off</li><li>Vision insurance</li></ul>Work Location: In person

Assistant Director of Nursing / MDS Coordinator

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

Oregon Health & Science University

<div>Department Overview:

The Nurse Manager is a Registered Nurse (RN) responsible for operational, human resource, 
quality, and financial leadership for one or more inpatient or ambulatory clinical units or 
programs. The Nurse Manager ensures the delivery of safe, high-quality, patient- and family centered care in alignment with organizational priorities and the Professional Practice Model. 
This role fosters a supportive and professional practice environment, promotes staff engagement 
and professional development, and partners with interdisciplinary teams to achieve excellence in 
clinical outcomes, operational efficiency, and patient experience
Function/Duties of Position:

The Nurse Manager differs from the Assistant Nurse Manager (ANM) in that the Nurse Manager 
holds primary accountability for operations, staffing, quality, and fiscal management for one or 
more inpatient or ambulatory units or clinical programs. The Nurse Manager operates with 
independent decision-making authority appropriate to the size, complexity, and scope of the 
assigned area(s), which may range from a single unit to multiple units or programs. 
1. Strategic &amp; Program Planning &mdash; The Nurse Manager develops and executes shorthand long-term goals aligned with organizational, division, and nursing priorities. This 
includes establishing measurable objectives, monitoring performance outcomes, and 
adjusting plans based on data, results, and stakeholder feedback. The Nurse Manager 
engages staff in shared governance and continuous improvement initiatives to advance 
clinical practice and operational efficiency. 
2. Operational Leadership &mdash; The Nurse Manager provides leadership for daily operations 
across assigned inpatient or ambulatory units, ensuring effective patient care delivery, 
patient flow, and workflow coordination. The role maintains visibility with staff, fosters 
open communication, promotes collaboration, and models accountability. The Nurse 
Manager also leads initiatives to enhance efficiency, integration, and overall patient 
experience. 
3. Financial &amp; Resource Management &mdash; The Nurse Manager develops, monitors, and 
manages operating budgets while tracking productivity, overtime, and resource 
utilization. The role implements cost-effective strategies while maintaining high 
standards of patient care and partners with leadership to plan for staffing, capital, and 
other resource needs to ensure the operational sustainability of the units or programs. 
4. Human Resources &amp; Staff Development &mdash; The Nurse Manager recruits, hires, 
evaluates, and develops staff while fostering engagement, recognition, and 
accountability. The role provides coaching and mentoring to emerging leaders, such as 
Assistant Nurse Managers or charge nurses and supports succession planning. The Nurse 
Manager ensures compliance with labor agreements, organizational policies, and 
professional practice standards, promoting a positive and professional work environment. 
5. Quality, Safety &amp; Performance Improvement &mdash; The Nurse Manager develops, 
implements, and evaluates quality, safety, and performance improvement initiatives 
appropriate to the scope of assigned units or programs. The role uses data and evidence-based practices to identify opportunities for improvement, mitigate risk, and drive high-quality patient outcomes. The Nurse Manager fosters a culture of safety, equity, and 
continuous learning, promoting excellence in care delivery. 
6. Professional Practice &amp; Collaboration &mdash; The Nurse Manager models ethical and 
evidence-based nursing practice consistent with the ANA Code of Ethics, Nurse Practice 
Act, and organizational values. The role engages in interdisciplinary collaboration to 
advance clinical care, operational effectiveness, and patient outcomes. The Nurse 
Manager represents units and programs in organizational initiatives and supports the 
development of a professional, inclusive practice environment that values diversity and 
promotes staff engagement.
Required Qualifications:
<ul><li>Bachelor of Science in Nursing (BSN) required.</li><li>Master&rsquo;s degree in nursing or related field (e.g., MBA with healthcare concentration,</li></ul>
MHA, MPH). 
<ul><li>Two (2) years of clinical nursing experience in a related specialty AND</li><li>One (1) year of recent relevant leadership experience (e.g., charge nurse, preceptor,</li></ul>
supervisor, or equivalent). 
<ul><li>Demonstrated ability to manage complex operations in a large, matrixed healthcare</li></ul>
environment. 
<ul><li>Unencumbered Oregon RN license required.</li><li>BLS for healthcare providers required.</li><li>Professional certification in nursing leadership (e.g., NE-BC, CNML) required within 2</li></ul>
years of hire.
Additional Details:

This position also comes with great benefits! Some highlights include: 
<ul><li>
Comprehensive health care plans that cover 100% for a full-time employee and 88% for dependents for .75 FTE and higher.</li><li>
$50K of term life insurance provided at no cost to the employee</li><li>
Two separate above market pension plans to choose from</li><li>
Paid time off- 208 hours per year (full-time), prorated for part-time</li><li>
Extended illness bank- 64 hours per year, prorated for part-time</li><li>
9 paid holidays per year</li><li>
Three weeks of paid parental leave</li><li>
Adoption assistance program (up to 5k)</li><li>
Substantial Tri-met and C-Tran discounts</li><li>
Tuition Reimbursement</li><li>
Innovative Employee Assistance Program (EAP)</li></ul>
Why apply to OHSU?: We are Oregon's only public academic health center. In addition to caring for patients, we lead groundbreaking research. We also train the next generation of health care professionals. As Portland's largest employer, we give you opportunities to learn and advance in a system of hospitals and clinics across Oregon and Southwest Washington. All are welcome. OHSU welcomes people of all ages, ethnicities, genders, national origins, religions and sexual orientations. We are striving to build an anti-racist, multicultural institution and encourage people with diverse backgrounds to apply. To request reasonable accommodation, contact askhr@ohsu.edu</div>

Nurse Manager

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

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