Provides assessment & monitoring of resource utilization, coordinates outside referrals, provider practice patterns, quality of care, & coordination of our members continuing care needs. Maintain & support a culture of compliance, ethics & integrity. Responsible for ensuring ongoing compliance for the department. Maintains knowledge of policies & procedures & performs in accordance w/ applicable regulatory requirements, external laws & accreditation standards as they relate to the department.
Essential Functions:
- Determines & manages appropriate levels of care & services; using clinical knowledge, established guidelines, & physician consultation
- Implements changes in contract benefits, state & federal regulations, & established review criteria guidelines
- Synthesizes & analyzes a large volume of data related to the member, benefits, eligibility, facilities, contracts, & clinical status to identify issues & facilitate problem solving that results in continuity of care, quality of care & optimal resource management for the patient
- Coordinates care w/ various internal & external customers to facilitate high quality, timely, & cost effective care & service
- Consults & educates other staff, physicians, departments & members regarding resource management options that provide high quality while efficiently using available resources
- In addition to defined technical requirements, accountable for consistently demonstrating service behaviors & principles defined by the KP Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives
- Also accountable for consistently demonstrating the knowledge, skills, abilities, & behaviors necessary to provide superior & culturally sensitive service to each other, to our members, & to purchasers, contracted providers & vendors
Qualifications:
Basic Qualifications:
- A minimum of 3 years of clinical experience in hospital setting, preferably ICU, CCU, Med-Surg
- Experience in utilization review, case management, discharge planning, & managed care
- Knowledge & experience w/ Medicare coverage guidelines & medical criteria such as Interqual or Milliman & Robertson
- Current unrestricted license as a RN in the State of Colorado
- Knowledge of quality & utilization review methods, statistical techniques, utilization management compliance standards, & regulatory elements
- Effective interpersonal, communication, & negotiating skills
Preferred Qualifications:
- Prefer clinical experience in hospital setting to be in ICU, CCU, Med-Surg
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.