Remote
The RN Utilization Coordinator assists leadership in coordinating and maintaining utilization review, which includes clinical and/or claims review for the purpose of resolving medical, contractual or technical issues. Incumbent performs team and project leadership, leads and participates in process improvement activities, and provides medical expertise to various internal areas. The Coordinator also researches, analyzes, and provides resolution to more difficult and complex cases
EDUCATION
Bachelor's degree in Nursing preferred.
LICENSING/CERTIFICATION.
Registered Nurse (RN) with current active state license in good standing in the state(s) where job duties are performed required.
EXPERIENCE
Minimum four (4) years' clinical practice nursing experience required, with experience preferred, but not limited to one of the following areas: medical-surgical nursing, surgical nursing, intensive care or critical care nursing.
Minimum two (2) years' utilization review experience.
Supervisory/management experience preferred.
ESSENTIAL SKILLS & ABILITIES
Oral & Written Communication
Clinical Judgment
Sound Judgment
Decision Making
Assess Training Needs
Researching
Analyze
Cultivating Relationships
Detail Orientation
Working Independently
Proficiency using basic computer skills in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding.
Codes of Conduct, Customer Relationship Management (CRM), Data Privacy, Health Insurance Portability & Accountability Act (HIPAA), Information Security, Instructional Materials, Microsoft Outlook, Patient Care, Patient Intake, Surgical Procedures, Teamwork, Utilization Management
Assists utilization team ensuring timely and accurate clinical and/or claims review, handling the more difficult and complex cases., Conducts clinical review cases and/or claims review analysis to assess and evaluate the efficiency and appropriateness of services for medical necessity through interpretation and review with evidenced-based criteria, clinical guidelines, corporate guidelines and policies and mandates and standards., Facilitates and promotes appropriate utilization review toward cost effective and cost containment measures based on evidence., Maintains a positive and productive work environment. Assists and promotes performance standards., Monitors utilization review to ensure team compliance with Association standards and Enterprise policies and procedures., Performs other duties as assigned., Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, Association standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety., Provides leadership to other team members in the development of skills and application to assigned work. Trains and coaches team members in all aspects of work, serving as a mentor., Remains current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts., Researches and compiles data from various reports and resources, identifying and analyzing problems and trends to develop solutions and recommendations., Serves as a resource for non-clinical staff., Works closely with leadership and other functional areas to coordinate and establish efficient processes and workflows.
This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.
Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.
Regular
ADA Requirements
1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.