ED Clinical UR Specialist

Kaweah Health • Visalia, CA

122d • $30 - $45

About The Position

Kaweah Health is a publicly owned, community healthcare organization that provides comprehensive health services to the greater Visalia area in central California. With more than 5,000 employees, Kaweah Health provides state-of-the-art medicine and high-quality preventive services in our acute care hospital, specialized health centers and clinics. Our eight-campus healthcare district has 613 beds and offers comprehensive health services across a broad continuum of care. It takes a special person to work for Kaweah Health. We serve a region where the needs are great, which makes the rewards even greater. Every day, we care for people facing unique challenges and in need of healing. Throughout it all, our focus is to make a difference, and we do — in the health of our patients, our loved ones, and our community.

Requirements

• CA LVN license required.
• Minimum of one year of clinical experience (acute care preferred).
• Experience in extracting data from a medical record.

Nice To Haves

• Degree in Human Services areas of Social Work, Psychology or other health-related fields with medical terminology or equivalence.
• Utilization review and/or coding experience.

Responsibilities

• Uses the results of quality of care/performance improvement activities to initiate changes in patient care practices.
• Collects clinical data for the RN to monitor quality and effectiveness of patient care.
• Identifies aspects of care that are important for quality monitoring.
• Participates in interdisciplinary teams.
• Performs Utilization Management to meet Case Management Goals.
• Reviews and records utilization review data to determine medical necessity for assigned caseload.
• Refers to Case Management team any variances that relate to concurrent review of the medical record.
• During chart review, is aware of criteria for quality variances.
• Complies with Kaweah Health Policy by reporting utilization variances to Case Management Committee and/or the P.I. department.
• Reviews medical records for admission and continued stay utilizing InterQual Severity of Illness and Intensity of Service.
• Issues a non-certification letter as directed by the Case Management Committee.
• Informs the Case Management Team and attending physician of any questionable or denied cases resulting from the review.
• Initiates further action by following guidelines set forth in the Hospital Case Management Plan.
• Collaborates and communicates with the patient/resident, family, physician, and other health care providers.
• Facilitates and coordinates placement of patients in appropriate long-term care facilities.
• Facilitates arrangements for acute transfer to other acute facilities when indicated.
• Assists case management team with discharge planning services.
• Assists patients with information and reviews Advance Directives.
• Participates in Continuum of Care rounds.
• Accumulates information on community resources and links patients, families and staff to appropriate services.
• Performs special audits/reports as required by the Case Management Team.
• Responsible for maintaining a safe workplace for the protection of the patient, staff and visitors.
• Attends Kaweah Health mandatory safety in-services.
• Assumes responsibility for the implementation of each individual patient program.
• Participates consistently in team conferences concerning the person served.
• Facilitates the exit/discharge process and arranges for follow-up and appropriate supportive services.
• Monitors the patient/family response to treatment and determines need for intervention and/or referral.
• Participates in training of all newly hired Care Coordination staff.
• Evaluates for efficient use of financial and personnel resources.

Benefits

• Full-Time Benefit Eligible
• Day - 10 Hour Shift

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees