Clinical UR Specialist
About The Position
The Clinical UR Specialist collaborates with RN Case Management staff and the multidisciplinary team to collect clinical data, monitor the quality and effectiveness of patient care, and support timely, safe discharge planning. The role performs utilization management and reviews medical records to determine medical necessity, admission appropriateness, continued stay, and resource use. It also supports care coordination, patient and family communication, referrals, placement, transfers, and discharge arrangements. For the inpatient rehabilitation program liaison function, the specialist supports implementation of each patient’s program, helps patients and families understand the program, promotes ongoing participation, takes part in team conferences, and coordinates discharge and follow-up services. The role also participates in staff training, promotes efficient use of resources, and maintains a safe workplace.
Requirements
- Current California LVN license.
- Experience extracting data from a medical record.
- At least one year of clinical experience; acute-care experience is preferred.
- For the ED department, at least two years of Case Management experience.
Nice To Haves
- Degree in a human services area such as Social Work or Psychology, or another health-related field, with medical terminology or equivalent.
- Utilization review and/or coding experience.
- Acute-care clinical experience.
Responsibilities
- Collect clinical data for RN staff to monitor the quality and effectiveness of patient care, and identify care aspects relevant to quality monitoring.
- Participate in interdisciplinary teams and use quality and performance-improvement results to support changes in patient care practices.
- Review and record utilization review data to determine medical necessity and ensure assigned inpatient records are current.
- Review medical records for admission, continued stay, and resource utilization using InterQual Severity of Illness and Intensity of Service criteria; review cases transferred into or out of special or intensive care areas using applicable criteria.
- Refer concurrent-review variances to the Case Management team, recognize potential quality variances, and report utilization variances as required by Kaweah Health policy.
- Issue non-certification letters as directed by the Case Management Committee.
- Inform the Case Management team and attending physician about questionable or denied cases identified by onsite Medi-Cal reviewers, CMRI, or private insurers, and initiate follow-up according to the Hospital Case Management Plan.
- Communicate and collaborate with patients or residents, families, physicians, and other healthcare providers, and make referrals that support continuity of care.
- Coordinate placement in appropriate long-term care facilities and acute transfers to other acute-care facilities when indicated.
- Assist the case management team with discharge planning, including coordination of equipment, home care, home health, and transportation services; provide information about Advance Directives.
- Participate in Continuum of Care rounds and connect patients, families, and staff with appropriate community resources.
- Complete special audits and reports as required by the Case Management team.
- Maintain a safe workplace, follow applicable OSHA, TJC, department, and safety-plan requirements, review designated safety and infection-control materials annually, maintain a current TB skin test, and attend mandatory safety training.
- Demonstrate an attitude that supports Kaweah Health values, department efforts, and teamwork.
- For the inpatient rehabilitation liaison function, implement each patient’s program, orient patients and families, support purposeful and goal-directed programming, promote ongoing participation, and participate in team conferences.
- Facilitate rehabilitation discharge and follow-up arrangements, monitor patient and family responses to treatment, and determine when intervention or referral is needed.
- Participate in training newly hired Care Coordination staff and assist them with departmental functions.
- Evaluate efficient use of financial and personnel resources and communicate alternatives to the RN or physician to maximize resource utilization.
- Provide care and services appropriate to the population served in the assigned unit or work area.
- Perform other duties as assigned.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
