MUST HAVE ACTIVE ALASKA LICENSE AT TIME OF SUBMISSION
MUST HAVE COVID VACCINES


Position Summary

This position oversees the day-to-day requirements
of Utilization Management & Review, authorizing acute and sub-acute
admissions at the Southeast Alaska Regional Health Consortium (SEARHC) Mount
Edgecumbe Medical Center. This position works intensively with advanced systems
to track and trend denials, build models for documentation improvement plans,
and coordinate with all areas and levels of the hospital. This position works
closely with the provider community to improve clinical documentation, and with
administration to ensure appropriate utilization of hospital resources.
Under
general supervision, provides professional assessment, planning, coordination,
implementation, and reporting of complex clinical data. Maintains compliance with regulations affecting utilization management. Provider communication and behavior change
can be challenging; this individual must be a master communicator and change
agent. Clinical background required, as this position will be required to read,
rapidly synthesize, and narrate a clinical event to patients third-party
coverage for accurate and timely authorization and reimbursement. Must be able
to understand and manipulate advanced systems and work with and synthesize
large relational data sets, providing descriptive/predictive/prescriptive
analytics to modify facility operational behavior.
Accountabilities
• Reviews
patients records and evaluates patient progress. Performs prospective (admission), concurrent, and retrospective reviews and reconsideration
reviews/appeals; collects data to determine appropriateness of admission and
extended stay; records and transmits assessment findings, evaluations, and review
decisions; completes reports on review decisions and activities; promotes
quality improvement by identifying and referring issues affecting patient
quality of care; insures compliance with Revenue Cycle billing processes,
monitors the audit of cyclic reviews; certifies admission based on medical
necessity. Analyzes
patient records and participates in interdisciplinary collaboration with
professional staff and Care Coordination team. Consults with the Care Coordination team regarding the level of nursing
care and collaborates with other departments in the evaluation of projects
affecting discharge plans.
• Facilitates
educational programs and advises physicians and other departments of
regulations affecting utilization management.
• Coordinates
and attends all Quarterly Utilization Review meetings and provides information
relative to the review process and any identified problems. Responsible for the agenda and meeting
minutes; policy oversight with committee approval; performs any reviews and
studies as delegated by the committee; serves primarily as a liaison between
the hospital and any peer review organization and/or any other review agencies.
• Documents
review information. Communicates results
to claims adjusters (i.e. Revenue Cycle).
Enters billing information as appropriate; prepares information for
notification letters from providers and employees. Receives and processes requests for appeal of
denials; responds to complaints per UR guidelines; maintains Utilization Review
and appeal logs.
• Supports
clinical improvement activities of SEARHC by providing quality review; records
and reports all information within scope and authority.
• Performs
any administrative duties; receives, logs, and files a variety of reports,
charts, client interactions and other documents; performs other duties as
assigned or required.
Baseline Qualifications
Education/Experience/Certifications

• Bachelors degree in Nursing

• Five (5) years clinical care or nursing experience or an equivalent combination of education and experience AND two (2) years experience in Utilization Review

• A valid, current, full, and unrestricted RN license in the State of Alaska

• Utilization Review certification through the ABQARP or equivalent

Knowledge, Skills & Abilities:
Knowledge

• Advanced knowledge in conducting and reviewing medical record for medical necessity.

• Working knowledge of ICD-10 and CPT coding.

• Working knowledge of regulations as set forth by The Centers for Medicare Medicaid Services, and the State of Alaska Department of Health and Social Services (DHSS)

• Efficient in MS Word and Excel

Skills

• Skill in providing effective nursing care, assessing patient situations and taking effective courses of action.

• Strong technology, systems, and analytical skills

Abilities

• Ability to communicate effectively with providers, staff, and patients.

• Strong written and oral communication skills.

• Strong organizational skills.