MUST HAVE ACTIVE ALASKA LICENSE AT TIME OF SUBMISSIONMUST HAVE/OBTAIN FLU VACCINEGeneral Description: Manages patient progression of care, promote evidenced-based protocols, ensure the appropriateness of interventions, and expedite care delivery for patients admitted. Directs patient care services to ensure a timely and appropriate patient discharge.Key Essential Functions and Accountabilities of the JobReviews patients records and evaluates patient progress. Performs continuing review of the patient hospitalization to specifically monitor the necessity for and appropriateness of hospitalization, length of stay, and quality of care. Provides these UM and review functions to the Purchased/Referred Care Services program for SEARHC beneficiary patients admitted to other facilities.Obtains and reviews necessary medical reports and treatment plans as requested by regulatory agencies or payers. Reviews and validates physician orders, reports progress and unusual occurrences on patients. Works with the MEH leadership, clinical care team and physicians to ensure healthcare services are appropriate and cost-effective. Collaborates with physicians, MEH leadership, and the clinical care team to ensure adherence to the UM/CM/DCP plan.Reviews new hospital admissions to assess patient condition(s) and needs in order to develop personalized treatment plans. Provides appropriate or required information to patients and/or their families regarding their healthcare benefits. Reviews patient records and participate in interdisciplinary collaboration with professional staff. Ensures maintenance of the Utilization Review Plan collaboration with the Utilization review staff Medical Director (or designated provider).Facilitates educational programs and advises physicians and other departments of regulations affecting UM/CM/DCP. Directs the coordination of patient care departments, ensuring treatment plans are based on the need of the patient and meet criteria approved by the hospital and any regulatory or payer requirements. Ensures documentation supports the UM functions and communicates with payers within required timeframes. Reviews information, communicates results to claims adjusters, and enters billing information appropriate. Prepares information for notification letters providers, staff, and patients.Received and processes request for appeal of denials. Responds to complaints per UM review guidelines. Maintains utilization review and appeal logs. Supports clinical improvements activates of SEARHC by providing quality review.Performs tumor registry functions for SEARHC.Other duties as assigned.Education, Certifications, and Licenses Required Bachelor s Degree in Nursing Case Management certification by recognized certifying organization (i.e., NCQA, CCMC) preferred can obtain within 24 months of hire. Active nursing license in Alaska or other U.S. state required.o Agency staff must have an active Alaska license. High school diploma or equivalent required.8 years clinical care or nursing experience, 3 years of which should be in chart review, risk management, or related quality serviceKnowledge of: Conducting and reviewing medical records for medical necessity, level of care, and public and private insurance reimbursement. Basic ICD-9 and CPT coding. Regulations as set forth by The Centers for Medicare Medicaid Services. Proficient in medical terminology, anatomy, physiology, and concepts of disease. Skills in: Providing effective nursing care, assessing patient situations and taking effective courses of action. Strong written and oral communication skills. Strong organizational skills. Ability to: Ability to communicate and collaborate effectively with providers, staff, and patients.

Shift: Will discuss at interview.

Specialty Type: Nursing

Sub Specialties: Care Manager

Nursing Certifications : CCMA

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