• Review precertification requests for medical necessity.
• Review clinical information for concurrent reviews, extending the Length of Stay for inpatients as appropriate.
• Use effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to:
o promote improved quality of care and/or life
o promote cost effective medical outcomes
o prevent hospitalization when possible and appropriate
o promote decreased lengths of hospital stays when appropriate
o prevent complications in patients under our care when possible
o provide for continuity of care
o assure appropriate levels of care are received by patients
• Provide appropriate referrals to Case Management.
• Identify appropriate alternative and non-traditional resources and demonstrate creativity in managing each case to fully utilize all available resources.
• Maintain accurate records of all interventions.
• Gathers all pertinent information from providers and facilities to ensure physician reviewers have sufficient information to make a decision to approve or deny services.
• Coordinates with non-clinical staff to ensure all documentation is completed timely and in a professional manner.
• Interfaces with internal resources including Medical Directors and other Health Services staff to ensure members receive the right care at the right time in the right setting by the right provider.
Skills/Knowledge/Abilities
Personal qualities that are desirable include the ability to work under stress, both with and without supervision; attention to detail and a tolerance for handling a heavy workload. Professional nursing theory, principles, and practices are also required. Demonstrated interpersonal and technical skills including the following:
• The principles and practices of utilization management.
• Effectively apply acute care medical/surgical nursing practices.
• Use clinical guidelines for medical necessity determinations.
• Demonstrated ability to problem-solve complex, multifaceted, emotionally charged situations.
• Ability to successfully manage conflict, negotiating “win-win” solutions.
• Strong organizational, task prioritization and delegation skills.
• Computer literacy on Microsoft Office products.
• Patient advocacy focus.
• Knowledge of required regulatory timelines to ensure department compliance with State contracts.
• Knowledge of basic computer applications with ability to adapt to new software programs.
• Excellent communication and people skills.
• Excellent typing skills.
• Strong writing skills.
Education and Experience
All candidates must have a registered nursing degree, preferably at the baccalaureate level, as well as some experience in the field of case management and/or utilization review.
If you feel that you have the skills we require, please respond to this posting with your contact information and your resume in a Word document. We look forward to hearing from you today!
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Job details are sourced from the employer's original posting.
Open job postingAbout the company
Healthcare Talent is assisting our client in their search for a Compliance Specialist, Delegation Oversight, for a vital position in their rapidly growing healthcare organization. In accordance with organizational policies, the candidate will maintain federal regulatory compliance for all pertinent matters and will performs compliance program activities including coordination of delegation oversight activities to ensure compliance with requirements.