Case Review Registered Nurse

Tuba City Regional Health Care Corporation•Tuba City, AZ

15h

About The Position

This position facilitates analysis of medical staff quality and performance data by coordinating the collection, analysis, and trending of required medical staff quality and peer review information, along with selected clinical outcome measurements. The Case Review RN assists medical staff with practitioner-specific quality monitoring and reporting, manages and investigates concerns about provider practice quality, and is responsible for Ongoing Professional Practice Evaluations and Focused Professional Practice Evaluations. The role supports the Peer Review Committee and other quality projects. It evaluates the quality and appropriateness of care provided by peers through a non-punitive, continuous-learning process intended to improve patient safety and practice standards. The position also establishes, promotes, and monitors seamless care for TCRHCC patients. The work includes reviewing records and clinical documentation, assessing the appropriateness and necessity of services, supporting utilization review and appeals, analyzing and reporting quality data, and coordinating continuity of care with outside providers and agencies. The position involves prolonged office computer work, walking through the hospital to review records, and standing to consult providers and clinical staff. Occasional travel, including to satellite health centers and for training, may be required. The employee may occasionally need to adapt to shift work and may encounter infectious diseases and other environmental hazards.

Requirements

Bachelor’s degree in nursing and a master’s degree in business administration or another healthcare-related master’s degree.
Valid, current, full, and unrestricted Professional Nursing License to practice in any U.S. state, the Commonwealth of Puerto Rico, or a U.S. territory.
Five years of supervisory experience in discharge planning, case management, or utilization review in an acute-care healthcare setting, or related healthcare clinical leadership.
Satisfactory performance in prior and current employment, supported by positive employment references.
References must address experience accessing community resources for patient referrals.
Ability to eliminate potential professional, organizational, and personal conflicts of interest or bias in internal review programs.
Ability to use systematic and scalable review processes that ensure accurate and reliable criteria and results and identify trends and potential issues in clinical staff performance, deficiencies, and errors.
Knowledge of diagnosis-related groups (DRGs) and documentation requirements.
Positive working relationships with others, high ethical standards, and no history of complaints.
Reliability and dependability, including reporting to work as scheduled without excessive absences.
Ability to assess varying skill levels and direct instruction accordingly.
Attention to detail, organization, and critical-thinking, reasoning, deduction, and inference skills.
Knowledge of report writing, graphical analysis, computer spreadsheets, and database programs.
Successful completion of interviews, background and reference checks, fingerprint clearance, physical examinations, and other required screenings.
Submission of all required employment documents and information without false, misleading, or incomplete information.
Ability to use computer applications, including Microsoft Word, Excel, and PowerPoint or other database-management applications.
Strong written and verbal communication skills and ability to work effectively with all organizational levels and medical staff.
Strong public-speaking skills and ability to deliver presentations and education to large groups of physicians and staff.
Ability to prioritize multiple projects and accommodate changing priorities.
Ability to manage interrelated data-analysis and reporting matters, resolve complications and controversial issues, and meet the described mental and emotional demands of the role.
Ability to meet the described physical demands, including prolonged computer use, walking, standing, occasional lifting, pushing, and pulling up to 10 pounds, and frequent use of vision, hearing, grasping, and fine-manipulation abilities.

Nice To Haves

Prior experience in hospital or clinical management.

Responsibilities

Review patient records and clinical documentation to assess the appropriateness and necessity of healthcare services and ensure quality and cost-effectiveness of care.
Resolve informal and formal complaints and grievances within the position’s jurisdiction, referring matters to higher management or the Risk Manager and/or Clinical Division when appropriate.
Thoroughly examine patient charts, clinical documentation, and billing information to assess the appropriateness and necessity of services provided.
Conduct chart reviews to identify issues involving the quality, timeliness, and appropriateness of patient care.
Refer cases to physician advisors for review and determination when appropriate.
Manage issues concerning provider practice quality; evaluate and investigate quality concerns; and conduct Ongoing Professional Practice Evaluations and Focused Professional Practice Evaluations.
Support the Peer Review Committee and other quality-related projects, including practitioner-specific quality monitoring and reporting.
Communicate and coordinate processes with outside providers to support continuity of patient care and patient advocacy among Navajo Area Indian Health Services/Service Units and federal and state entities.
Develop and implement policies and procedures concerning case management eligibility, alternate resource programs, referral and notification processes, and interdepartmental relationships and responsibilities.
Promote access to the appropriate level of care, prevent over- or under-utilization of resources, maximize use of alternate resources, and support continuity of care.
Assist with review, research, and decisions in the first-level appeal process with Purchase Referred Care.
Provide clinical expertise and support, educate, and oversee the quality and completeness of clinical documentation, including admission and continued-stay reviews using clinical documentation enhancement guidelines for selected patient populations.
Collaborate with the Physician Advisor or designee to lead and facilitate the Utilization Review Committee.
Develop and interpret statistical, financial, and trend reports; provide data to the PI Committee; and submit required reports on outcomes, clinical quality documentation, and insurance medical-necessity criteria.
Complete task training for routine cleaning and decontamination of surfaces contaminated by communicable disease.
Perform other assigned duties as needed.