Clinical UR Specialist

Kaweah Delta Health Care District•Visalia, CA

About The Position

The Clinical UR Specialist works collaboratively 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 reviews for an assigned caseload, including evaluating medical necessity, admission and continued-stay appropriateness, and resource utilization. It also supports patient and family coordination, referrals, care transitions, and—in the designated department—inpatient rehabilitation program liaison activities.

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.
Ability to provide care and services appropriate to the population served in the assigned unit or work area.

Nice To Haves

Degree in a human services field such as Social Work or Psychology, or another health-related field, with medical terminology or equivalent.
Utilization review and/or coding experience.

Responsibilities

Collect clinical data and identify aspects of care important for quality monitoring; use quality and performance-improvement results to support changes in patient care practices.
Participate in interdisciplinary teams and Continuum of Care rounds.
Review and record utilization review data for an assigned caseload, keeping inpatient records current and determining medical necessity.
Refer medical-record concurrent-review variances to the Case Management team and report utilization variances to the Case Management Committee and/or Performance Improvement department as indicated by policy.
Review medical records using InterQual Severity of Illness and Intensity of Service criteria to assess admission, continued stay, and resource utilization appropriateness, including cases transferred into or out of special or intensive care areas.
Participate in designated subcommittee reviews and issue non-certification letters as directed by the Case Management Committee.
Inform the Case Management Team and attending physician about questionable or denied cases resulting from reviews by onsite Medi-Cal reviewers, CMRI, or private insurance companies, and take further action according to the Hospital Case Management Plan.
Coordinate referrals and continuity-of-care provisions; facilitate placement in long-term care facilities and acute transfers when indicated.
Assist with discharge planning, including coordination of equipment, home care, home health, and transportation services.
Provide patients with information about Advance Directives and accumulate information on community resources, linking patients, families, and staff to appropriate services.
Perform special audits and reports as required by the Case Management Team.
Maintain a safe workplace, follow safety plans and applicable OSHA and TJC standards, review specified safety and infection-control materials annually, maintain a current TB skin test, complete annual safety testing, and attend mandatory safety in-services.
Support Kaweah Health values, department efforts, and teamwork.
For the inpatient rehabilitation program liaison assignment, implement individual patient programs; orient patients and families; support purposeful, goal-directed participation; attend team conferences; facilitate discharge and follow-up services; and monitor patient and family responses to treatment to determine intervention or referral needs.
Participate in training newly hired Care Coordination staff and assist employees with department functions.
Evaluate efficient use of financial and personnel resources and communicate alternatives to the RN and/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.