Utilization Management Nurse
We appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will help us potentially place you in a position that meets your objectives and those of the organization. Qualified applicants are considered for positions without regard to race, color, religion, sex (including pregnancy, childbirth and breastfeeding, or any related medical conditions), national origin, ancestry, age, marital or veteran status, sexual orientation, gender identity, genetic information, gender expression, military status, or the presence of a non-job related medical condition or disability (mental or physical).
Our Mission.. Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system.
**$2,000. Sign on Bonus**
Under direction of the Kern Health Systems (KHS) Medical Director and Director of Utilization Management, the Utilization Management Nurse, RN, is responsible for clinical review for members receiving care in an inpatient setting. Reviews the appropriateness and medical necessity of admissions and continuing inpatient confinement utilizing clinical guidelines and Medicaid criteria. Makes first level approval determinations and appropriately refers cases to the Medical Director for second review when case does not meet criteria.
Incumbents in this position are competent in all essential areas of utilization management. Utilization Management Nurses work independently under general direction, nurses at this level may need support and guidance in more complicated case reviews or discharge plans. This position involves frequent communication with members, caregivers, medical providers, and KHS staff telephonically, electronically and potentially in-person. UM Nurses may be assigned at on-site facilities or may work at KHS offices.
MAJOR DUTIES & RESPONSIBILITIES:
- Conducts clinical inpatient reviews – prospective, concurrent and retrospectively.
- Works in collaboration with hospital staff and other network providers for efficient and timely discharge planning.
- Initiates discharge planning activities starting at admission.
- Works closely with facility discharge planners and case managers.
- Refers cases to Case Management and Disease Management programs when clinically indicated.
- Ensures that all clinical documentation is timely and up to date so that the daily census report is reliable and accurate including timely documentation of all discharges.
- Refers cases to the KHS Social Worker for social interventions when indicated.
- Communicates, consults and collaborates with KHS Medical Director on an as needed basis.
- Serve as a liaison to community providers and KHS Members.
- Acts as a preceptor to new staff.
- Makes first level approval determinations when request meets medical necessity and benefit criteria within required turnaround times.
- Identifies and refers cases for quality of care, coordination of benefits, and third party liability issues as appropriate.
- Benefits interpretation to include coordination of care for medically necessary services that are not covered under the KHS Plan e.g. CCS, Mental Health, Long Term Care, State Waiver Programs.
- Presents cases and rationale to Medical Director for potential denial determinations.
- Ensures that case notes are timely, concise, and indicate exactly why the patient is meeting inpatient level of care criteria on a daily basis. Documents such on a concurrent basis.
- Performs retrospective reviews within 3 business days of notification of admission (weekend admissions, etc.)
- Maintains and updates authorizations in Core Claims Adjudication system to enable timely payment of claims.
- Performs at 85% or higher on inter-rater reliability audits.
- Perform other related duties.
- Coordinates services with other key KHS departments (i.e. Member Services, Provider Relations)
CORE COMPENTENCIES / KNOWLEDGE & SKILL REQUIREMENTS
- Lead by example to support a positive work environment that values patient advocacy, respectful listening, diverse expression of opinion and constructive conflict resolution;
- Adheres to KHS’s Code of Ethics and Business Conduct and all company policies; e.g., confidentiality, attendance, safety/security, use of equipment and technology, appearance and demeanor;
- Represent KHS in a positive manner to all members, caregivers, staff and external stakeholders;
- Demonstrate commitment to continuous improvement;
- Strong knowledge of acute chronic care nursing principles, methods and common treatments;
- Strong knowledge of common human diseases and usual and customary methods of treatments;
- Demonstrated knowledge of medical terminology;
- Knowledge of acute hospital organization and interrelationships of various clinical and diagnostic services;
- Ability to assess and judge the clinical performance of physicians and other health professionals;
- Knowledge of ICD10 and/or CPT coding;
- Ability to effectively evaluate medical records to determine appropriateness and necessity of care;
- Demonstrated knowledge of health care delivery systems;
- Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individual at all levels both inside and outside of KHS;
- Ability to use tact and diplomacy to diffuse emotional situations;
- Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards;
- Basic skills in Word and Excel with basic ability to enter data into and navigate through a database;
- Demonstrated ability to respect and maintain the confidentiality of all sensitive documents, records, discussions and other information generated in connection with activities conducted in, or related to, patient healthcare, KHS business or employee information and make no disclosure of such information except as required in the conduct of business;
- Demonstrated ability to commit to and facilitate an atmosphere of collaboration and team work;
- Self-directed, with proven ability to work independently with minimum supervision;
- Demonstrated ability to multi-task in an interrupt-driven environment and complete assignments on a timely basis;
- Strong attention to detail; work accurately and at a reasonable rate of speed;
- Compliant with KHS policies and procedures; performs the job safely and with respect to others, to property, and to individual safety.
EDUCATION, EXPERIENCE & TRAINING REQUIRED:
- Registered Nurse with an active, current, unrestricted license
- Minimum of two years (2) full-time clinical experience in acute care, community health setting, public health nursing or chronic disease management required;
- Experience working with patients and caregivers regarding self-care and disease management required;
- Experience working in case management or care coordination is a plus;
- Experience with MCG Clinical guidelines, Medi-cal, and California Children’s Services preferred,
- Knowledge of Kern County Community resources for seniors and people with disabilities is a plus;
- Bachelor’s Degree from an accredited school or equivalent in Nursing, Health Administration or related healthcare field preferred.
We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis.