utilization review 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

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

VanderHouwen

<div>
 Our client is seeking a detail-oriented and clinically strong Registered Nurse who excels at applying sound judgment to complex healthcare scenarios. This individual will bring a balance of analytical thinking, regulatory awareness, and clear communication to ensure fair and accurate appeal outcomes. The ideal candidate is collaborative, adaptable, and confident navigating both clinical and non-clinical conversations in a remote environment.
 
 
 
 This role is a Hybrid model in Idaho. Applicants must be able to maintain flexibility to occasionally support work outside of standard business hours may be required.
 
 
 
 
 Clinical Appeals Nurse (RN) Responsibilities
 
 
 
 <ul>
 <li>
 Conduct comprehensive clinical reviews of member and provider appeals, ensuring alignment with medical necessity, policies, and standards of care.
 </li>
 <li>
 Apply clinical expertise to interpret medical records, benefit plans, and contractual requirements to support accurate determinations.
 </li>
 <li>
 Collaborate with physician advisors when needed to validate complex or high-risk clinical decisions.
 </li>
 <li>
 Ensure all appeal decisions meet regulatory, accreditation, and organizational compliance requirements.
 </li>
 <li>
 Provide guidance and education to non-clinical team members on clinical aspects of appeals and case reviews.
 
 
 </li>
 </ul>
 
 Clinical Appeals Nurse (RN) Qualifications
 
 
 
 <ul>
 <li>
 Must hold a current, unrestricted Registered Nurse (RN) license in Oregon, Washington, Idaho, or Utah; Bachelor&rsquo;s degree in Nursing preferred.
 </li>
 <li>
 Minimum of 2 years of experience in health insurance, utilization management, or clinical appeals review, plus at least 3 years of direct patient care experience.
 </li>
 <li>
 Strong knowledge of medical terminology, procedures, coding systems (CPT, ICD, HCPCS), and clinical guidelines (e.g., MCG).
 </li>
 <li>
 Proven ability to interpret medical records, claims, and benefit structures, and translate findings into clear, concise written determinations.
 </li>
 <li>
 Familiarity with regulatory and accreditation standards, along with proficiency in Microsoft Office tools and remote work environments.
 
 
 </li>
 </ul>
 
 Compensation: $28-$30/hr. (DOE)
 
 
 VanderHouwen Contractors Enjoy Exceptional Benefit Perks!
 
 
 
 As an eligible contract employee with VanderHouwen, you'll have access to a full suite of benefits designed with your well-being in mind. Our comprehensive package includes medical, dental, vision, life insurance, short- and long-term disability, and a matching 401(k) to help secure your future.
 
 
 
 Meet VanderHouwen
 
 
 
 What kind of recruiter do you see yourself working with? One who prioritizes your best interest, no matter what? VanderHouwen does, and we're in it for the long game! Our recruiters focus on YOU, building meaningful, long-term relationships while developing a deep understanding of companies' staffing needs and workplace cultures. This approach helps us find an ideal job match that aligns with your unique career aspirations and goals.
 
 
 VanderHouwen is an award-winning, Women &amp; Diversity-Owned, WBENC certified professional staffing firm. Founded in 1987, VanderHouwen places experienced professionals across the nation! Our recruitment teams specialize in either Technology and IT, Engineering, Human Resources, or Accounting and Finance career markets. Partner with us to land your next exciting career!
 
 
 VanderHouwen is an Equal Opportunity Employer and participates in E-Verify. VanderHouwen does not discriminate based on race, color, religion, sex, national origin, age, disability, or any other characteristic protected by applicable local, state, or federal civil rights laws.
 
 
</div>

Clinical Appeals Nurse (RN)

Lexington Health

<div>Center for Best Practice
 
Full Time 
Day Shift 
8-430 


Lexington Health is a comprehensive network of care that includes six community medical and urgent care centers, nearly 80 physician practices, more than 9,000 health care professionals and Lexington Medical Center, a 607-bed teaching hospital in West Columbia, South Carolina. It was selected by Modern Healthcare as one of the Best Places to Work in Healthcare and was first in the state to achieve Magnet with Distinction status for excellence in nursing care. Consistently ranked as best in the Columbia Metro area by U.S. News &amp; World Report, Lexington Health delivers more than 4,000 babies each year, performs more than 34,000 surgeries annually and is the region's third largest employer. 


Lexington Health also includes an accredited Cancer Center of Excellence, the state&rsquo;s first HeartCARE Center, the largest skilled nursing facility in the Carolinas, and an Alzheimer&rsquo;s care center. Its postgraduate medical education programs include family medicine and transitional year residencies, as well as an informatics fellowship.<div><div><div><h2 class="jobSectionHeader">
Job Summary</h2>
</div><div>
The Outcomes Coordinator will guide efforts to assess and improve performance and coordinate use of measurement data to monitor, document, and ultimately improve the quality of care and services provided at Lexington Medical Center. Assists in evaluation, analysis, maintenance and development of system functionality of electronic health record (EPIC) to meet clinical objectives including participating in project plan development/tracking and workflow analysis. Responsible for data integrity and follows well defined processes for maintaining data integrity. Serves as expert regarding DNV, SC DHEC and other disease specific regulatory requirements and serves in an active role to achieve compliance to standards.
</div></div><div><div><h2 class="jobSectionHeader">
Minimum Qualifications</h2>
</div><div>
Minimum Education: Bachelor of Science in Nursing; 
Candidates pursuing ADN to MSN may be considered if they have completed all of the BSN curriculum as verified by the educational institution and complete the MSN within one year of employment or transfer to the role. 
Minimum Years of Experience: 5 Years of experience as a registered nurse, including at least 2 years of utilization review, quality assurance, or case management experience and 2 years experience in leadership role. 
Substitutable Education &amp; Experience (Optional): Refer to Mandatory Certification Requirements P&amp;P for required education/certification for Coordinator serving on Stroke Team 
Required Certifications/Licensure: Currently licensed as Registered Nurse by the State Board of Nursing for South Carolina. 
Required Training: None
</div></div><div><div><h2 class="jobSectionHeader">
Essential Functions</h2>
</div><div><ul><li>Facilitate the delivery of quality, cost-effective patient care and the achievement of desired outcomes for patients, families, and the organization by coordinating data collection and analysis for performance improvement activities.</li>
<li>Integrates and coordinates performance improvement measurement activities so as to avoid duplication of effort and ensure a comprehensive, patient population-focused strategy.</li>
<li>Coordinates continuous readiness activities for DNV and other regulatory requirements in respective areas.</li>
<li>Participates in the development, implementation, evaluation, and revision of new programs, protocols, teaching plans, and other guidelines for care of identified patient populations.</li>
<li>Provides educational offerings that contribute to the professional development of others (ex. PDCA, PI, DNV requirements).</li>
<li>As requested, designs clinical studies utilizing knowledge of research design and statistical methods. Involved in ongoing research related to the care of the ACS patient.</li>
</ul></div></div><div><div><h2 class="jobSectionHeader">Duties &amp; Responsibilities</h2>
</div><div><ul><li>Performs statistical analysis of data, summarizes findings, and prepares reports. Able to communicate effectively through presentation skills in several formats for different audiences.</li>
<li>Implements data collection system which maximize use of existing databases and minimize the need for manually collected data.</li>
<li>Utilizes nationally-developed practice guidelines &amp; Benchmarks and other research-based practice recommendations in the selection of the process and outcome indicators to be measured.</li>
<li>Participates in data collection. Evaluates and makes recommendations for improving data collection methods and accuracy. Works closely with clinical areas to coordinate and improve data collection.</li>
<li>Participates on CQI teams/task forces/committees. Facilitates / leads teams utilizing CQI tools and methods.</li>
<li>Develops and maintains performance measurement data collection systems and processes that are accessible, efficient, and retrievable.</li>
<li>Functions as change agent by participating and supporting the change management process.</li>
<li>Works collaboratively and communicates effectively with administration, IT and clinical care teams through participation in the planning, development, evaluation and maintenance of the Clinical Information Systems.</li>
<li>Build professional skills by maintaining awareness of health care environment and information systems technology.</li>
<li>Acquires appropriate continuing education credits for own professional development and maintenance of current knowledge of outcomes management and related fields (minimum 25 hours per year).</li>
<li>Performs all other duties as assigned.</li>
</ul>
</div></div></div>We are committed to offering quality, cost-effective benefits choices for our employees and their families:
<ul>
<li>Day ONE medical, dental and life insurance benefits</li>
<li>Health care and dependent care flexible spending accounts (FSAs)</li>
<li>Employees are eligible for enrollment into the 403(b) match plan day one. LHI matches dollar for dollar up to 6%.</li>
<li>Employer paid life insurance &ndash; equal to 1x salary</li>
<li>Employee may elect supplemental life insurance with low cost premiums up to 3x salary</li>
<li>Adoption assistance</li>
<li>LHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employment</li>
<li>Tuition reimbursement</li>
<li>Student loan forgiveness</li>
</ul>
Equal Opportunity Employer 
It is the policy of Lexington Health to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. Lexington Health strives to provide a discrimination-free environment, and to recruit, select, on-board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to, lactation. Lexington Health endeavors to upgrade and promote employees from within the hospital where possible and consistent with the employee&rsquo;s desires and abilities and the hospital&rsquo;s needs.</div>

Outcomes Coordinator RN - Center for Best Practice

Butler Memorial Hospital

<div>Job Summary: 
The Case Managers are experienced Registered Nurses who interact with the patient, families, physicians and other members of the 
interdisciplinary team to facilitate quality and cost effective care. An essential component to all roles includes the evaluation of medical 
necessity and intensity of service of each admission to arrive at decisions regarding medical appropriateness for the requested level of 
care. Communicates with the various payers/insurance companies to authorize services and ensure appropriate reimbursement to the 
facility. Actively promotes collaboration among all interdisciplinary care providers, including physicians to effectively identify needs for 
continued inpatient care or appropriate alternate levels of care. There is coordination to affect an appropriate discharge plan with the 
Case Managers ensuring arrangements of placement/services upon discharge. Assist to identify and make efforts to correct delays in 
services, fragmentation of care and gaps in communication. Patient outcome monitoring and participation in continuous performance 
improvement are also requirements in this role. 
Education 
Minimum: 
Graduate of a Registered Nurse Program 
Preferred: 
Bachelor Degree in Nursing 
Registration/Certification/Licensure: 
Current PA RN license 
Preferred: Healthcare Provider CPR 
Experience 
Minimum: 
Three years recent clinical experience. 
Preferred: 
Managed care or previous Case Management/Utilization Review experience. 
Other Requirements: 
Excellent communication skills and skills in customer service. Demonstrates leadership ability. Commitment to the delivery of quality 
patient care with the ability to develop and maintain effective, professional relationships with all members of the health care team. 
Status: 
Non-Exempt

Physical Requirements: 
The following frequency definitions apply to all Physical Requirements unless otherwise noted: 
Occasional: (0-1/3 of day , 0 - 2.5 hrs/day, 1 - 4 reps/hr) 
Frequent: (1/3 -2/3 of day , 2.5 - 5.5 hrs/day, 5 -24 reps/hr) 
Constant: (&gt; 2/3rd of day , &gt; 5.5 hrs/day, &gt; 24 reps/hr) 
First Name xxxxx 
Middle Name xxxxx 
Last Name xxxxx 
Position Code 10.5070000.0000.236 
Position Name CASE MANAGER 
Department Name BMH Case Management 
Facility Name Butler Memorial Hospital 
Employee Number xxxxx 
NOTE: An asterisk (*) indicates that the item is an essential function. 
Non-Material Handling 
Standing* - Remaining on one's feet in an upright position remaining stationary. -FREQUENT 
Walking* - Remaining upright on one's feet, and moving about. -FREQUENT 
Sitting * - Body remains in a seated position. -FREQUENT 
Stooping - To bend the body downward and forward by bending the spine at the waist. - OCCASIONAL 
Bending - To flex the upper body forward. - OCCASIONAL 
Twisting - To rotate the upper body forward. - OCCASIONAL 
Climbing - To move the body in any direction on equipment or structures that do not include stairs or ladders. - N/A 
Ladders - To ascend and descend ladders. - N/A 
Stairs - To ascend and descend stairs. - FREQUENT 
Kneeling - To move the body downwards and come to rest on both hands and both knees - OCCASIONAL 
Squatting - To move the body downwards by bending both knees. - OCCASIONAL 
Crouching - To bend the body forward and downward by bending the spine and the legs. - OCCASIONAL 
Crawling - To move the body forward or backwards on hands and knees. - N/A 
Reaching Horizontal - To extend the arms and hands outward, remaining under shoulder height - OCCASIONAL 
Reaching Overhead - To extend the arms and hands up and out over shoulder height. - OCCASIONAL 
Grasping - Using functional gripping of the hand to handle an object. - CONSTANT 
Finger Manipulation - To manipulate objects with the use of fingers. - CONSTANT 
Seeing - Using visual feedback to accomplish a task or activity. - CONSTANT 
Hearing - Using sound feedback to accomplish a task or activity - CONSTANT 
Repetitive Upper Extremity Use - Using the arms and/or hands continuously or more than 2/3 of the total time. - CONSTANT 
Repetitive Lower Extremity Use - Using the legs and/or feet continuously or more than 2/3 of the total time. - CONSTANT 
Material Handling 
Pushing* - To exert a force upon an object in order to move it in a certain direction. Pushing refers to moving an object away from the 
person. 
CONSTANT 
Up to 20# 
Pulling* - To exert a force upon an object in order to move it in a certain direction. Pulling refers to moving an object towards the 
person. 
CONSTANT 
Up to 20# 
Lift - Floor to waist 
CONSTANT 
Up to 20# 
Lift - Waist to shoulder 
CONSTANT 
Up to 20# 
Lift - Shoulder to overhead 
CONSTANT 
Up to 20# 
Carrying - To transport an object or article using the arms or hands (&gt; 10 feet) 
CONSTANT 
Up to 20# 

Environmental Factors 
Working alone - OCCASIONAL 
Working in cramped quarters - FREQUENT 
Constant interruptions * - CONSTANT 
Working with hands in water - N/A 
Use of power tools - N/A 
Working on ladders/scaffolding - N/A 
Exposure to vibration - N/A 
Exposure to dust - N/A 
Exposure to noise (constant) - N/A 
Exposure to electrical energy (outlets, etc) - N/A 
Exposure to termperature changes (heat, cold, humidity), that require special clothing - N/A 
Exposure to slippery walking surfaces - N/A 
Exposure to solvents, grease, oils - N/A 
Exposure to radiant energy, i.e. computer terminal (more than 4 hours per shift) * - CONSTANT 
Working with bloodborne pathogens - N/A 
Cardiovascular Energy Requirements - Physical Demand 
Physical 
Demand 
Met 
Level 
Examples of similar activity intensity 
Sedentary to 
Light 
0 - 3.5 Light house cleaning, washing dishes, serving food, food shopping, sitting, standing, computer work. 
Medium 3.6 - 6.3 
House work (mopping, scrubbing), health club exercising, treadmill work, stretching, yoga, walk/run-play 
with children, aerobic class, dancing, carrying bucket/wood, auto body repair, shoveling snow, golf 
(carrying clubs). 
Heavy to Very 
Heavy 
&gt; 6.4 
Calisthenics (push up, pull up, sit up, vigorous effort), carrying groceries upstairs, shoveling coal, bailing 
hay, fire fighting, sawing by hand, splitting wood. 
As relates to this position: 
Sedentary to Light - CONSTANT 
Medium - N/A 
Heavy to Very Heavy - N/A

. Specific Job Responsibilities (Essential Functions): 
1. Performs admission as well as continued stay review of designated cases through established decision support criteria (Interqual) accurately 
identifying Severity of Illness/Intensity of Service to determine appropriateness of admission and ensure appropriate reimbursement. Focuses on 
Observation cases to determine appropriate action/follow up necessary in relationship to medical necessity; i.e. discharge/transition to inpatient 
status. Demonstrates understanding and efficiency in physician referrals/tasking to EHR. 
2. Provides clear documentation of selected medical necessity criteria as well as interventions and obtained authorizations. Demonstrates the ability 
to navigate the Navinet On Line Highmark process, the Allscripts case management module, Meditech and EMR. 
3. Understands and applies the many reimbursement strategies of the various payers and makes appropriate decisions relevant to this information 
(i.e. per diem/DRG, case Rate, observation, etc). Completes all required authorizations/pre-certifications to ensure appropriate reimbursement to 
the facility. 
4. Serves as an organizational collaborator for the patient to promote appropriate, efficient quality care. Collaborates with the Social Worker and 
health care team to ensure timely discharge planning; demonstrating efficiency in arranging for patient Post Discharge Needs: home infusion 
therapy, medications, DME, placement, transportation etc. 
5. Remains knowledgeable and participates in ongoing performance improvement activities within the department as well as on an organizational 
level; CoP (Conditions of Participation); MEIM, Freedom of Choice; Delay Days, LOS/Readmission Reduction initiatives, HF clinic referrals, identifying 
barriers to discharge, fragmentation in patient care, etc. 
II. Organizational Responsibilities: 
1. Completed mandatory education, annual competencies and department specific education within established timeframes. 
2. Completed annual employee health requirements within established timeframes. 
3. Maintained license/certification, registration in good standing throughout fiscal year. 
4. Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self. Identifies and 
works to reduce potentially unsafe patient care or other safety practices. 
5. Adheres to regulatory agency requirements, survey process and compliance.</div>

CASE MANAGER

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