utilization review nurse

Advanced Health Coordinated Care Organization

<div>
 We are currently hiring a
 
 Part-time
 
 
 REMOTE Utilization Review Nurse!
 
 If you are a licensed nurse with excellent critical thinking skills, have experience in acute care settings and utilization review, and value being part of a team that makes a difference, you may be the right person for the position!
 
 Apply today!
 
 
 
 
 Classification:
 
 NON-EXEMPT |
 
 Status &amp; Schedule:
 
 PART-TIME, 20-HRS/WEEK, GENERALLY MONDAY &ndash; FRIDAY, BUT MAY INCLUDE ADDITIONAL HOURS TO MEET THE NEEDS OF THE POSITION
 
 
 
 Location:
 
 REMOTE, LOCAL TO OREGON STRONGLY PREFERRED
 
 
 
 Work Location:
 
 OR, CA, AZ, TX, FL
 
 
 
 Salary:
 
 $35.29 - $47.37/HOURLY
 
 
 
 Department:
 
 MEDICAL SERVICES/UTILIZATION REVIEW |
 
 Reports to:
 
 DIRECTOR OF MEDICAL SERVICES |
 
 Supervision Exercised:
 
 NON-SUPERVISORY
 
 
 
 JOB PURPOSE: Utilization Review Nurse
 
 
 
 The Clinical Review Nurse is responsible for providing clinically efficient and effective utilization management. Reviews prior authorization requests for appropriate care and setting by following evidence based clinical guidelines, medical necessity criteria and health plan guidelines. Reviews and applies hierarchy of criteria to all referral and preauthorization requests from the PCP's and specialists that require a medical necessity determination. Is involved in assuring that the patient receives high-quality cost-effective care. Uses sound clinical judgement and managed care principles in the coordination of care. Prepares any case that does not meet medical necessity guidelines for medical appropriateness of procedure, service, or treatment for review with the Physician Reviewer for a decision.
 
 
 
 QUALIFICATIONS, EDUCATION, And EXPERIENCE
 
 
 
 <ul>
 <li>
 Nursing degree from an accredited nursing program
 </li>
 <li>
 Unrestricted Oregon RN license
 </li>
 <li>
 Experience with a similar population in health plans or managed care
 </li>
 <li>
 Experience administering OHP, Medicare benefits or utilization review highly preferred.
 
 
 
 </li>
 </ul>
 
 ESSENTIAL RESPONSIBILITIES: Licensed Utilization Review
 
 
 
 <ul>
 <li>
 Maintains clinical expertise and knowledge of scientific progress in nursing and medical arena and incorporates this information into the clinical review and care coordination processes
 </li>
 <li>
 Performs clinical review for appropriate utilization of medical services by applying appropriate medical necessity criteria guidelines
 </li>
 <li>
 Authorizes healthcare services in compliance with contractual agreements, Health Plan guidelines and appropriate medical necessity criteria
 </li>
 <li>
 Provides accurate and timely documentation within internal system supporting rational of decision based on clinical review
 </li>
 <li>
 Identifies members who are appropriate for care coordination programs and collaborates with the Medical Management team for care coordination of the member's needs along the continuum of care
 </li>
 <li>
 Meets timeliness standards for referral and prior authorization activities
 </li>
 <li>
 Sends appropriate notifications for Third Party Liability (TPL) and/or possible Stop Loss
 </li>
 <li>
 Forward relevant information of members requiring special interventions to Advanced Health
 </li>
 <li>
 Participate in quality and organizational process improvement activities and teams when requested
 </li>
 <li>
 Assist in audit preparation as directed
 </li>
 <li>
 Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
 </li>
 <li>
 Handle confidential information and materials appropriately and maintains a secure work area
 </li>
 <li>
 Maintains the confidentiality of all company procedures, results, and information about patients, contracts, and all other proprietary information regarding company business.
 </li>
 <li>
 Ensure compliance with company policies and procedures as applicable to area(s) of responsibility
 </li>
 <li>
 Handle confidential information and materials appropriately and maintain a secure work area
 </li>
 <li>
 Other duties as assigned
 
 
 
 </li>
 </ul>
 
 ESSENTIAL RESPONSIBILITIES: ORGANIZATIONAL TEAM MEMBER
 
 
 
 <ul>
 <li>
 Participate in quality and organizational process improvement activities and teams when requested
 </li>
 <li>
 Support and contribute to effective safety, quality, and risk management efforts by adhering to established; policies and procedures, maintaining a safe environment, promoting accident prevention, and identifying and reporting potential liabilities
 </li>
 <li>
 Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner
 </li>
 <li>
 Work collaboratively by mentoring new and existing co-workers, building bridges, and creating rapport with team members across the organization
 </li>
 <li>
 Provide excellent customer service to all internal and external customers, which includes team members, members, students, visitors, and vendors, by consistently exceeding the customer&rsquo;s expectations
 </li>
 <li>
 Recognize new developments and remain current in [position&rsquo;s expertise] best practice standards and anticipate organizational modifications
 </li>
 <li>
 Advance personal knowledge base by pursuing continuing education to enhance professional competence
 </li>
 <li>
 Promote individual and organizational integrity by exhibiting ethical behavior to maintain high standards
 </li>
 <li>
 Represent organization at meetings and conferences as applicable
 
 
 
 </li>
 </ul>
 
 KNOWLEDGE, SKILLS, And ABILITIES
 
 
 
 <ul>
 <li>
 Knowledge of OHP program requirements, benefit package, eligibility categories, and Oregon Division of Medical Assistance Program (MAP) rules and regulations preferred
 </li>
 <li>
 Knowledge of ICD, CPT, and HCPCS codes
 </li>
 <li>
 Proficient in Milliman Clinical Guidelines (MCG)
 </li>
 <li>
 Strong attention to detail
 </li>
 <li>
 Ability to think and work independently with minimum supervision
 </li>
 <li>
 Provide critical attention to detail for accuracy and timeliness
 </li>
 <li>
 Ability to manage multiple tasks and remain flexible in a dynamic work environment
 </li>
 <li>
 Ability to report to work as scheduled, and willingness to work a flexible schedule when needed
 </li>
 <li>
 Proficient in Microsoft Office Suite and Windows Operating System (OS)
 </li>
 <li>
 Training in or awareness of Health Literacy, Poverty Informed, Systemic Oppression, language access and the use of healthcare interpreters, uses of data to drive health equity, Cultural Awareness, Trauma-Informed Care, Adverse Childhood Experiences (ACEs), Culturally and Linguistically Appropriate Service (CLAS) Standards, and universal access
 </li>
 <li>
 Knowledge and understanding of how the positions&rsquo; responsibilities contribute to the department and company goals and mission
 </li>
 <li>
 Knowledge of federal and state laws including OSHA, HIPAA, Waste Fraud and Abuse
 </li>
 <li>
 Awareness and understanding of equity, diversity, inclusion, and the equity lens: ability to analyze the unfair benefits and/or burdens within a society or population by understanding the social, political, and environmental contexts of policies, programs, and practices
 </li>
 <li>
 Excellent people skills and friendly demeanor
 </li>
 <li>
 Critical thinking skills of using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems
 </li>
 <li>
 Attention to detail and organization skills
 </li>
 <li>
 Ability to handle stress and sensitive situations effectively while projecting a professional attitude
 </li>
 <li>
 Ability to communicate professionally, both conversing and written
 </li>
 <li>
 Ability to work with diverse populations and interact with people of differing personalities and backgrounds
 </li>
 <li>
 Sensitive to economic considerations, human needs and aware of how one&rsquo;s actions may affect others
 </li>
 <li>
 Ability to organize and work in a sensitive manner with people from other cultures
 </li>
 <li>
 Poised; maintains composure and sense of purpose
 
 
 
 </li>
 </ul>
 
 WORKING CONDITIONS
 
 
 
 This position must have the ability to remain in a stationary position, occasionally move about inside the office to access office machinery, printer, etc., frequently communicate and exchange accurate information.
 
 
 
 Work Condition:
 
 Remote Work Environment
 
 
 <ul>
 <li>
 Employee generally works within a remote work from home environment.
 </li>
 <li>
 Travel may be required on occasion.
 </li>
 <li>
 Hours of operations and specific staff scheduling may vary based on operational need.
 
 
 
 </li>
 </ul>
 
 Exposed to:
 
 
 
 <ul>
 <li>
 Employee is responsible for maintaining a safe work environment that is conducive to successful productivity and work output.
 </li>
 <li>
 Machines, equipment, tools, and supplies used: Constantly operates a computer or other office productivity machinery or software, such as fax, copier, calculator, multi-line telephone system, or scanner.
 </li>
 <li>
 May answer a high volume of telephone calls, complete documentation, and use computer programs to either obtain or record information.
 
 
 
 </li>
 </ul>
 
 Multiple Duties:
 
 Must be able to work under conditions of frequent interruption and be able to stay on task.
 
 
 This job description is intended to provide only basic guidelines for meeting job requirements. This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of DOCS Management Services employees. Other duties, responsibilities and activities may change or be assigned at any time with or without notice.
</div>

REMOTE Utilization Review Nurse - Managed Care

Hines & Associates, Inc.

<div>Description:

Nurses &ndash; are you looking for a change? Want to work no nights, no weekends, and no holidays? Be able to work from home 50% of the time once trained? Check out Hines &amp; Associates!
ABOUT US:
Hines is a nationwide, independent leader in personalized managed health care, focused on what&rsquo;s important to you&mdash;comprehensive services with the program excellence and cost containment that you demand. Hines &amp; Associates, Inc.&rsquo;s reputation as an industry leader is founded on over three decades of innovative and professional health care excellence. Serving all aspects of the industry, Hines is committed to conserving health care dollars while ensuring quality care through effective programs and personalized service.
WHAT WE OFFER:<ul><li>
Competitive salary and benefits, including medical, dental, vision, long-term care, short-term disability, long-term disability, company paid and voluntary life insurance. Critical Illness, accident insurance and flexible spending also available!</li><li>
401k plan with company match, fully vested after 1 year.</li><li>
No weekends and nights!</li><li>
Paid Holidays</li><li>
Work-life balance.</li><li>
Remote/hybrid setting (once trained)</li></ul>
ROLE DESCRIPTION:
This individual will utilize clinical knowledge and communication skills to obtain patient specific information regarding patient condition and proposed treatments and procedures to determine if illness and/or proposed services meet acceptable criteria sets and acceptable nursing practice guidelines for outpatient treatment or inpatient confinement. This individual will certify treatment for confinement when criteria and/or practice guidelines are met, in accordance with the health benefit plan, disability, workers compensation regulations and state and federal regulations. If these conditions do not appear to be met, this individual will defer decision to a second level reviewer. This individual interfaces with case managers and disease management nurses on active cases involved in other Hines&rsquo; programs.
*****This is a Monday through Friday position, 9:30 AM to 6:00 PM.******
RESPONSIBILITIES AND PERFORMANCE:<ul><li>
Completes first level reviews within the scope of practice relevant to the clinical area(s) addressed in the initial clinical review. General Medical-Surgical nursing is sufficient to be relevant to the clinical areas addressed in most initial clinical reviews. .</li><li>
Demonstrates ability to assess a patient&rsquo;s current medical status, including complications and untoward events, which may require additional intervention. Provides certification of medical, disability and workers compensation cases.</li><li>
Demonstrates a thorough understanding of criteria sets and their limitations including when a second level review is required.</li><li>
Evaluates appropriateness of current plan of care.</li><li>
Assesses aftercare needs, implements discharge planning and/or case management referral in a timely manner.</li><li>
Maintains knowledge of current advances and trends in medical care.</li><li>
Demonstrates knowledge of URAC guidelines, Hines policies and procedures, and standards of practice and their revisions. Able to attain and maintain the minimal quality assurance performance standards.</li><li>
Demonstrates assertiveness in completion of precertification and concurrent review within the guidelines of URAC, disability, workers compensation regulations, and state and federal requirements and according to the Hines policies and procedures.</li><li>
Performs onsite evaluations as needed or requested.</li><li>
Additional responsibilities as assigned.</li></ul>
PM21
COMMUNICATION:<ul><li>
Communicates with hospital staff, physicians, other providers and Hines customer contacts in a competent, calm, effective and professional manner.</li><li>
Effectively communicates the need to refer to a higher-level review for questionable plans of treatment.</li><li>
Provides written documentation concerning the clinical information obtained regarding the patient&rsquo;s status, benefit and claim concerns, and validation of criteria.</li><li>
Communicates knowledge of policies and procedures, URAC guidelines, disability and workers compensation regulations, state and federal requirements, and standards of practice.</li></ul>
PERSONAL AND PROFESSIONAL:<ul><li>
Participates in self-evaluation by identifying areas of strength and limitations and offers and accepts constructive criticism.</li><li>
Creative and assertive.</li><li>
All First Level Reviewers are required to sign and honor a confidentiality statement at the time of hire and annually at the time of performance reviews.</li></ul>
Requirements:

QUALIFICATIONS:<ul><li>
Registered Nurse with valid, unrestricted, current nursing license in the state or territory of the United States where employed. For mental health/substance abuse, licensed medical professional with an unrestricted license in the state or in a state that has licensure reciprocation with the state of the office location the employee is working in may perform first level reviews. Accepted licensure includes but is not limited to RN, LMSW, LMHC.</li><li>
Must have Mental Health or Substance Abuse experience.</li><li>
Successful completion of UR nurse orientation program.</li><li>
Minimum of 3 years recent acute clinical practice required, 5 years preferred.</li><li>
Managed care, disability or workers compensation experience helpful but not mandatory.</li><li>
Customer service oriented.</li></ul>
*Hines welcomes diversity and as an equal opportunity employer all qualified applicants will be considered regardless of race, religion, color, national origin, sex, age, sexual orientation, gender identity, disability or protected veteran status.*</div>

Behavioral Health Utilization Review Registered 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.
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Concurrent Review Nurse

Brighton Health Plan Solutions

<div>
 
 About The Role
 
 
 
 BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, contractual requirements, and a member&rsquo;s benefit coverage while working remotely.
 
 
 
 Primary Responsibilities
 
 
 
 <ul>
 <li>
 Performs clinical utilization reviews using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures
 </li>
 <li>
 Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments
 </li>
 <li>
 Collaborates with healthcare partners to ensure timely review of services and care
 </li>
 <li>
 Provides referrals to Case management, Disease Management, Appeals &amp; Grievances, and Quality Departments as needed
 </li>
 <li>
 Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
 </li>
 <li>
 Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate
 </li>
 <li>
 Triages and prioritizes cases and other assigned duties to meet required turnaround times
 </li>
 <li>
 Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations
 </li>
 <li>
 Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements
 </li>
 <li>
 Duties as assigned
 
 
 </li>
 </ul>
 
 Essential Qualifications
 
 
 
 <ul>
 <li>
 Current Licensed Practical Nurse (LPN) with state licensure. Must retain active and unrestricted licensure throughout employment
 </li>
 <li>
 Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
 </li>
 <li>
 Must be able to work independently
 </li>
 <li>
 Must be detail oriented and have strong organizational and time management skills
 </li>
 <li>
 Adaptive to a high pace and changing environment- flexibility in assignment
 </li>
 <li>
 Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review
 </li>
 <li>
 Proficient in MCG and CMS criteria sets
 </li>
 <li>
 Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred
 </li>
 <li>
 Working knowledge of URAC and NCQA
 </li>
 <li>
 2+ years&rsquo; experience in a UM team within managed care setting
 </li>
 <li>
 3+ years&rsquo; experience in clinical nurse setting preferred
 </li>
 <li>
 TPA Experience preferred
 
 
 </li>
 </ul>
 
 About
 
 
 
 At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you&rsquo;ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you&rsquo;ll be encouraged to bring your authentic self to work with all of your unique abilities.
 
 
 Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today&rsquo;s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today&rsquo;s challenges into tomorrow&rsquo;s solutions.
 
 
 Come be a part of the Brightest Ideas in Healthcare&trade;.
 
 
 
 Company Mission
 
 
 
 Transform the health plan experience &ndash; how health care is accessed and delivered &ndash; by bringing outstanding products and services to our partners.
 
 
 
 Company Vision
 
 
 
 Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.
 
 
 Powered by JazzHR
 
 
 DLcZRrpbP4
</div>

Utilization Management Nurse

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

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

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