Clinical Reviewer, Utilization Management (Full Time, 40, Day) Job at The Queen's Health Systems
Responsibilities
I. JOB SUMMARY/RESPONSIBILITIES:
II. TYPICAL PHYSICAL DEMANDS:
III. TYPICAL WORKING CONDITIONS:
IV. MINIMUM QUALIFICATIONS:
A. EDUCATION/CERTIFICATION AND LICENSURE:
B.EXPERIENCE:
o Knowledge of and ability to use Microsoft Office (i.e., Word, Excel, Outlook).
o Ability to learn/develop the skills necessary to implement the clinical documentation improvement activities, including learning coding requirements, using analytical problem solving skills, and engaging physicians and nursing staff in the improvement process.
oAbility to communicate effectively, both orally and in writing, with diverse professionals including physicians, nurses, case managers, billing and coding staff.
- Develops, organizes, and implements the utilization review processes in order to achieve efficient cost effective resource management while maintaining quality of care.
- Reviews for safe and effective patient care, customer satisfaction, and quality outcomes. Responsibilities include regular review of patient records for clear documentation of patient’s clinical condition as well as the type and intensity of services provided.
- Negotiates payer reimbursement and analyzes the data for systemic hospital improvement efforts.
- Works to assure that there is consistent, effective and appropriate use of healthcare services. Record reviews are done at admission, concurrently throughout the inpatient stay, and after patient is discharged.
- Works in concert with The Queen’s Medical Center (QMC) Utilization Management Plan.
II. TYPICAL PHYSICAL DEMANDS:
- Essential: sitting, walking, stooping/bending, finger dexterity, seeing, hearing, speaking, repetitive arm/hand motions.
- Frequent: standing, climbing stairs, lifting weight up to 25 pounds, carrying usual weight of 5 pound up to 20 pounds, reaching above, at and below shoulder level.
- Occasional: kneeling, walking on uneven ground, squatting.
- Operates computer, printer, copier, facsimile, and telephone.
III. TYPICAL WORKING CONDITIONS:
- Not substantially subjected to adverse environmental conditions.
- Rotates on-call 24/7 for all utilization management questions and expedited Quality Improvement Organization (QIO) appeals, providing clinical documentation to support patient’s medical clearance for discharge.
IV. MINIMUM QUALIFICATIONS:
A. EDUCATION/CERTIFICATION AND LICENSURE:
- Current Hawaii State License as a Registered Nurse.
- Bachelor’s degree in nursing.
- Current certification as a Certified Case Manager (CCM) through Commission for Case Manager Certification (CCMC) or Accredited Case Manager-Registered Nurse (ACM-RN) through National Board for Case Management (NBCM) preferred.
- Care Guidelines Specialist in Case Management certificate from MCG Health preferred.
B.EXPERIENCE:
- Two (2) years nursing experience.
- Prior acute medical/surgical nursing experience preferred.
- Experience to demonstrate:
o Knowledge of and ability to use Microsoft Office (i.e., Word, Excel, Outlook).
o Ability to learn/develop the skills necessary to implement the clinical documentation improvement activities, including learning coding requirements, using analytical problem solving skills, and engaging physicians and nursing staff in the improvement process.
oAbility to communicate effectively, both orally and in writing, with diverse professionals including physicians, nurses, case managers, billing and coding staff.
Equal Employment Opportunity
Equal Opportunity Employer / Disability / Vet
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