Medical Management - Utilization Management RN 145-2016
工作总结：负责对利用请求的临床审查，评估和实施整体会员，机构化人口，高风险成员和其他需要使用的成员的潜在护理机会协调。作为利用管理团队的积极团队成员职能。关键责任：·执行室外患者及辅助服务以及住院和急诊后服务的利用情况审查。·根据临床审查标准确定医疗必要性和服务的合适性。· 根据确定的时间框架，准确记录所有审查决定和联系提供商和成员。· 适当识别并将未符合既定临床标准的病例提交给医疗总监。· 恰当确定并向医疗管理领导层报告质量问题。· 适合地识别可能发生的护理管理计划病例。· 与医生和其他供应商合作以促进整个卫生保健连续服务。·执行精确数据输入。· 如有必要/要求，向其他工作人员传递适当信息。·参与继续教育倡议。· 根据需要与其他部门合作。· 按照分配的职责执行其它任务。资格：· 知识管理护理和相关团体福利计划。· 有强大的口头和书面沟通技能。· 在解释材料或情况时具有逻辑性和善于判断能力。· 了解社区资源。· 必须具备优秀的组织技能，能够完成多项任务。·熟练掌握微软应用程序。· 非常好的时间管理和文档化技能。· 成功完成医疗保健制裁背景调查。教育/经验：· 从认可的护士学院毕业。· 现有，活跃的无限制许可证在俄克拉荷马州担任注册护士。· 优先拥有3年急性护理经验。· 优惠具有与人口健康工作两年的经验。• 优先获得前期放松计划或案例管理经验。
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JOB SUMMARY:
Responsible for clinical review of utilization requests and assessment and implementation of potential coordination of care opportunities for overall membership, institutionalized populations, high risk members, and other members identified with at risk or high utilization needs. Functions as an active team member of the Utilization Management Team.
KEY RESPONSIBILITIES:
- Performs utilization review of outpatient and ancillary services as well as inpatient and post-acute services when indicated.
- Determines medical necessity and appropriateness of services using clinical review criteria.
- Accurately documents all review determinations and contacts providers and members according to established timeframes.
- Appropriately identifies and refers cases that do not meet established clinical criteria to the Medical Director.
- Appropriately identifies and refers quality issues to Medical Management leadership.
- Appropriately identifies potential cases for Care Management programs.
- Collaborates with physicians and other providers to facilitate provision of services throughout the health care continuum.
- Performs accurate data entry.
- Communicates appropriate information to other staff members as necessary/required.
- Participates in continuing education initiatives.
- Collaborates with other departments as needed.
- Performs other duties as assigned.
QUALIFICATIONS:
- Knowledge of managed care and associated group benefit plans.
- Possess strong oral and written communication skills.
- Ability to reason logically and to use good judgment when interpreting materials or situations.
- Knowledge of community- based resources.
- Must have excellent organizational skills and be able to perform multiple tasks.
- Proficient in Microsoft applications.
- Excellent time management and documentation skills.
- Successful completion of Health Care Sanctions background check.
EDUCATION/EXPERIENCE:
- Graduation from accredited School of Nursing.
- Current, active, unrestrictive license to practice as a Registered Nurse in the State of Oklahoma.
- Three years of acute care experience preferred.
- Two years of experience working with population health preferred.
- Previous discharge planning or case management experience preferred.
- Managed care experience a plus.
CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin
Originally posted on Himalayas