Qualifications - RN or LPN with Active, unrestricted license to practice in state of assignment. Responsibilities - Perform Utilization Review - pre-authorization, concurrent and retrospective review as needed for inpatient/or outpatient services and/or predetermination reviews for services or levels of care requiring authorization according to the market requirements and/or policies. EEO Adventist HealthCare is an Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex, national origin, age, marital status, disability or any other basis prohibited by law.
- 3 - 5 years experience in an acute clinical setting required; experience in geriatric nursing, renal, cardiac and or endocrinology a plus.
- Experience in utilization review, disease management and retrospective reviews are a primary responsibility within this position.
- Knowledge of and experience in using Milliman and Interqual Care Guides preferred.
- Familiarity with utilization review modules in information system.
- Ability to handle multiple tasks and variable case load, creative problem solving and willingness to work as a team member to strategize future program enhancements.
- Knowledge of health care delivery system, utilization review and or case review approaches and procedures.
- Experience of state and federal regulatory requirements affecting care coordination services, specifically CMS, 3808's, HIPAA, etc.
- Knowledge of community resources in the area and government programs.
- Ability to communicate effectively in English, both verbally and in writing.
- Proficiency in PC skills such as the Windows work environment, Word and Excel.
- Ability to foster interdisciplinary relationships among health care team members at all levels of the organization.
- Manage assigned workload within established performance standards by completing the assigned retrospective reviews.
- Demonstrate fiscal responsibility for the Hospital by entering all clinical information accurately and preventing risk of denial.
- Serve as a resource for recognized areas of expertise.
- Establish and maintain positive relationships with providers, members and caregivers through telephonic and/or onsite visits.
- Establish positive relationships with treating physicians and other health care providers through collaborative problem solving.
- Participate in discharge planning process with hospital/or inpatient facility staff, ensuring adequate and appropriate disposition and post discharge plans.
- Promote positive customer relations.
- Maintain open communication flow with internal Disease Review/Complex Case Management/or Social Services staff to facilitate smooth transition and follow-ups as member is transferred from one level of care and/or service to another.
- Actively support the faith based mission of the organization.
