SUMMARY

Responsible for assuring the receipt of high quality, cost efficient medical outcomes for those enrollees identified as having the need for inpatient/outpatient precertification.

 

ESSENTIAL DUTIES & RESPONSIBILITIES Review precertification requests for medical necessity, referring to the Medical Director those that require additional expertise. Review clinical information for concurrent reviews. As part of the UMRN program, conduct ongoing availability, monitoring and oversight of non-clinical staff activities. Establish effective rapport with other employees, professional support service staff, customers, clients, patients, families, and physicians. Employ effective use of knowledge, critical thinking, and skills to: Advocate quality care and enhanced quality of life. Prevent patient complications during hospital stay. Advocate decreased hospital stay when appropriate. Maintain accurate records of all patient related interactions. Maintain regular and punctual attendance. Perform other duties as assigned.

 

SUPERVISORY RESPONSIBILITIES

None.

 

MINIMUM QUALIFICATIONS Bachelor of Science in Nursing (BSN) is required. Minimum of two (2) years of prior experience in Utilization Management. Must possess a current, active, full, and unrestricted Registered Nurses (RN) licensed in Colorado, be able to practice using a nurse compact state license or have a license from any United States jurisdiction (with no limitations, stipulations or pending adverse actions). Knowledge of medical privacy and confidentiality (Health Insurance Portability and Accountability Act [HIPAA]), and accreditation standards of Accreditation Association for Ambulatory Health Care (AAAHC), The Joint Commission (TJC), and Clinical Practice Guidelines (CPGs). Must have knowledge and experience, or demonstrate comprehension during training, with software and databases currently employed at the MTF (e.g., Microsoft Office, Access, Excel, and PowerPoint; Composite Health Care System [CHCS], Armed Forces Health Longitudinal Technological Application [AHLTA]). Must have a working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Current Version (ICD), and Current Procedural Terminology- Current Version (CPT) coding; and McKesson (InterQual) and/or Milliman Care Guidelines. Must have and maintain current certification in Basic Life Support (BLS) from the American Red Cross. This certificate must be current at all times. Must obtain and maintain the site's required health screening and immunization requirements. Must obtain and maintain all required documents, certifications, licenses, etc. listed on the credentialling checklist, sent by Katmai’s Credentialing Specialist, for this position for initial hire. Must obtain and maintain any necessary security access and/or background checks.

 

DESIRED QUALIFICATIONS & SKILLS Certification by a Utilization Management-specific program such as Certified Professional in Healthcare Management (CPHM) is desired. Working knowledge of computer applications/software to include Microsoft Office programs, MS Outlook (e - mail), and internet familiarity is required. The ability to input, extract, and format data from established databases is desired. Ability to effectively read, write and speak English in order to communicate with all patients and other healthcare providers. Ability to effectively communicate and collaborate with a diverse group of people for the purpose of informing the healthcare team of plans/actions, for teaching/education to benefit the patient/family and organization. Effectively uses appropriate communication format in addressing professional issues. Excellent written communication skills to perform accurate documentation, both written and electronic, of all activity in accordance with requirements. Must demonstrate ability to apply critical thinking skills and expertise in resolving complicated healthcare, social, interpersonal, and financial patient situations.