Auditor, Utilization Management Care Continuum

The Auditor will be auditing clinical criteria reviews to ensure correct level of care and educating utilization management staff across the Continuum of Care.

• Monitors/Audits UM nurses criteria reviews to ensure referral integrity is maintained and to ensure adherence to MCG guidelines. Provides immediate feedback to both employee and manager. Conducts timely and consistent coaching/monitoring with a goal of instilling and maintaining confidence and empowerment while identifying areas in need of improvement.


• Analyzes and communicates with UM Management team regarding patterns and trends in performance and maintains systems for ensuring follow-up. Identifies resources and techniques that would assist in quality improvement. Defines individual and team needs to improve and recognize competencies and to relay non-restrictive flow of information.


• Keeps informed of all changes to MCG guidelines, workflows, system enhancements and regulations, which could affect the criteria review and referral process. Improves efficiencies and employee satisfaction through effective partner tools and resources.


• Provides ongoing training/education utilizing MCG modules, MCG case studies and other methods deemed appropriate to enhance the teams understanding of MCG and improve the quality of criteria reviews completed.


• Identifies areas for workflow improvement and provide solutions to streamline processes.


• Reports weekly results of audits to the UM managers and UM director. The individual in this position will be required to maintain proficiency in KPHC and stays current with updates impacting workflow. Auditors must be able to coach on an individual basis and lead small group learning and development sessions addressing components of referral integrity.


• Perform daily adits on patient referrals completed by the UM (PCC) nurse team. Utilize standardized auditing tool daily. Identify training needs based on trends and deficits noted in the audit proces. Outreach to the Lead PCC in each region and managers to provide feedback on  criteria reviews and referral integrity.


• Acts as subject matter expert and resource for clinical teams related to referral integrity. Responds to questions/concerns from the teams and supervisors respective to utilization review and management. Escalates issues as appropriate to the manager or UM Director. Conduct targeted audits of new hires and individuals consistently not meeting quality standards, provide input to the managers/director for improvement plans. Maintains adequate production, quality, and timeliness of audits, as defined by the position.


• Real Time Historical Data: Identifies variances and trends, makes recommendations for improvements to enhance referral integrity/quality.


• Input to Improve Quality: Works with leadership team to identify process, system and training needs to achieve improved accurate and efficient referral management. Works with PCC regional leads and manager for one-on-one and small group training. Document all one-on-one education, training and remdiation done. Work as a liaison between the PCC team and UM leaders to identify and resolve barriers to accurate information concerning criteria reviews and referral integrity.


• Reporting/Documentation: Produces weekly audit summary reports to analyze audit findings and trends; Identify areas of targeted training. Work with leadership team to train, mentor and remediate the PCC team, as indicated.

Qualifications:

• Minimum five (5) years of nursing experience.


• Minimum two (2) years of acute utilization management experience.

• BSN or bachelors degree in health care administration, other health related field, OR four (4) years of experience in a directly related field.


• High School Diploma or General Education Development (GED) required.

• This job requires credentials from multiple states. Credentials from the primary work state are required before hire. Additional Credentials from the secondary work state(s) are required post hire.

• Registered Nurse License (Virginia) within 6 months of hire AND Registered Nurse License (Maryland) within 6 months of hire

      OR

• Compact License: Registered Nurse within 6 months of hire

• Registered Nurse License (District of Columbia) within 6 months of hire

• Basic Life Support

• Demonstrated strong clinical knowledge base, judgment, and experience.


• Ability to analyze, integrate, and use quantitative data information in making business decisions and problem solving.


• Must be able to work in a Labor Management Partnership environment.

• Previously trained as a Quality and/or UM auditor


• ACM or CCM preferred.