Registered Nurse (utilization Review)

Definition

**IF YOU PREVIOUSLY APPLIED FOR THIS POSITION, YOU DO NOT NEED TO RE-SUBMIT YOUR APPLICATION**

Position Summary : Under general supervision of the Senior Nurse Manager, Case Management (SNMCM). The Utilization Review Registered Nurse will compile and review the medical information of individual patients and determine medical necessity. The goal is to balance the quality of patient care with cost efficiency to maximize the continuity of care a patient receives. This job class is treated as FLSA Exempt.

Essential Functions: Essential functions may vary amongpositions,butmayincludethefollowingtasks,knowledge,abilities,skills,andothercharacteristics. This list of tasks is ILLUSTRATIVE ONLY and is not intended to be a comprehensive listing of tasks performed by all positions in this classification.

Examples of Tasks

Review medical necessity and appropriateness of services before authorizing and/or collaboration with physician review

Educates patients on denials to help them better understand the limitations of their benefits

Compile and review medical information and insurance coverage and provide clinical consultation regarding Utilization Management to providers and other colleagues within the River People Health Center

Respond to all requests appropriately, accurately, and timely according to Case Management and Primary Care guidelines

Identify alternative, cost-effective resources and collaborate with community partners for services and equipment not known to HHS/River People Health Center staff.

Ensure appropriate data is tracked to monitor the effectiveness/outcomes of the Utilization Management program and use the data to drive decisions and implement performance improvement strategies related to Utilization Management

Maintain current knowledge regarding commercial and government payers as well as Joint Commission regulations/guidelines/criteria related to Utilization Management

Knowledge in areas such as Medicare and Medicaid Utilization Management regulations to include Medicare Administrative Contractor (MAC) for updated National Coverage Determinations (NCD) as well as Local Coverage Determinations (LCD)

Provide ongoing education to case managers, social workers, providers, finance and other colleagues as related to Utilization Management

Prepare succinct written clinical case summaries to include rationale for recommended services for internal and external audiences

Participate in development, implementation, teaching, evaluation and revision of Utilization Management policies while participating in Utilization Management Committee meetings

Seek consultation from appropriate disciplines/departments as required to expedite care and facilitate timely and accurate documentation of clinical reviews

Identify and facilitate resolution of system processes that impede Utilization Review functions

Participate in quality improvement initiatives and contribute to developing and implementing evidence-based protocols and guidelines for Utilization Management

Performs other job related duties as signed to maintain and enhance departmental operations.

Knowledge, Skills, Abilities , and Other Characteristics:

• Knowledgeofthehistory,culture,laws,rules,customsandtraditionsoftheSRPMIC.
• Knowledgeofthepurpose,currentissues,projects,organization,policies,andemployeeresponsibilities of the division to which assigned.
• Strong verbal and written communication skills
• Experience with E.H.R's and community resources
• Focused customer service skills and excellent problem-solving skills
• Ability to use critical thinking and to problem solve in a professional manner
• Strong clinical assessment and critical thinking skills to develop effective Utilization Management plans
• Excellent communication skills to effectively educate, counsel, and advocate for patients and their families
• Empathy and compassion to provide emotional support and address the needs of patients
• Ability to work in a multidisciplinary team and collaborate effectively with healthcare professionals
• Proficiency in using electronic health record systems and other healthcare software for accurate documentation and information retrieval
• Strong organizational and time management skills to prioritize tasks and manage medical services referrals effectively
• Knowledge of evidence-based guidelines and best practices in Utilization Management
• Initiates medical necessity reviews to determine if initial clinical information meets medical necessity criteria or collaborate with provider to obtain additional medical necessity documentation
• Leads and proactively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff".

Minimum Qualifications

•Education& Experience:

• Registered Nurse with active Arizona license
• Minimum of 1 - 2 years' experience including Primary Care Case Management
• Two years of clinical nursing experience in acute care or outpatient setting
• Experience in utilization management preferred
• CCM (Certified Case Manager required)
• Continuing education and professional development in utilization review and management

•Equivalency: Any equivalent combination of experience and education that will allow the applicant to satisfactorily perform the duties of the job may be considered when filing the position.

• Underfill Eligibility: An enrolled Community Member whom closely qualifies for the minimum qualifications for a position may be considered for employment under SRPMIC Policy 2-19, Underfill

Special Requirements

• Employment is contingent upon successful completion of an extensive background check and drug screening. Employees in, and applicants applying for, jobs providing direct services to children are subject to the "Community Code of Ordinances", Chapter 11, "Minors", Article X. "Investigation of Persons Working With Children".

Prior to hire as an employee, applicants will be subject to drug and alcohol testing. Will be required to pass a pre-employment background/fingerprint check.

"SRPMIC is an Equal Opportunity/Affirmative Action Employer" Preference will be given to a qualified : Community Member Veteran, Community Member, Spouse of Community Member, qualified Native American, and then other qualified candidate.

In order to obtain preference, the following is required: 1) Qualified Community Member Veteran (DD-214) will be required at the time of application submission 2) Qualified Community Member (must provide Tribal I.D at time of application submission),3) Spouse of a Community Member (Marriage License/certificate and spouse Tribal ID or CIB is required at time of application submission), and 4) Native American (Tribal ID or CIB required at time of application submission).

Documents may be submitted by one of the following methods:

1) attach to application

2) fax (480) 362-5860

3) mail or hand deliver to Human Resources.

Documentation must be received by position closing date.

The IHS/BIA Form-4432 is not accepted .

Your Tribal ID/CIB must be submitted to HR-Recruitment-Two Waters.

Benefits:

The SRPMIC offers a comprehensive benefit package including medical, dental, vision, life, disability insurance, and a 401(k) retirement plan. In addition employees enjoy vacation and sick leave and 13 paid holidays.