Utilization Review Coordinator jobs in Flagstaff, AZ

Navajo Preference Employment Act

Overview

Incumbent serves as an Outpatient/Inpatient Case Manager/Utilization Review Registered Nurse (CM/UR RN) for TCRHCC and is responsible for direct supervision and supportive contact for the specific group of identified patient assignments and high-risk patients.  The CM/UR RN is responsible for designing and managing a continuum of care focusing on empowering clients to achieve demonstrable outcomes and self-sufficiency.  The CM/UR RN is responsible for assessment, service planning, and resource acquisition, monitoring progress and initiating and responding to emerging client needs.  The CM/UR RN performs Utilization Review and Management/Clinical Documentation Chart Reviews of patients in the acute clinical care setting, ambulatory care setting and will conduct UR reviews as required. The CM/UR RN will work closely with the Social Work (MSW) Case Manager on Discharge Planning and Care Transitions. The CM/UR RN will work closely with the Physician Advisor and participate on the UR Committee as well as conduct Clinical Documentation Chart Reviews related to peer review, financial or insurance determination, or claims denials. The CM/UR RN will link the client with Community Social Service providers, health care providers, substance abuse, and mental health providers to achieve specific goals.  The CM/UR RN will have experience working with culturally diverse low-income populations having multiple barriers to self-sufficiency such as: illiteracy, welfare dependency, domestic violence, substance abuse, and mental health issues.  The CM/UR RN will work with a multidisciplinary team within the service delivery setting.  The CM/UR RN will be committed to Case Management Services and have some collaboration with Purchased and Referred Care (PRC) formally known as Contract Health Services, providing assistance with the PRC Case Specialist.  The CM/UR RN will be responsible to the Director of Care Coordination.

Qualifications

NECESSARY QUALIFICATIONS

Education:

Associates Degree in Nursing (ADN), must obtain bachelor’s in nursing within two (2) years of hire

License/Certification:

• Must have and maintain current Basic Life Support (BLS) certification by the American Heart Association (AHA) throughout employment
• A valid, current, full and unrestricted Professional Nursing License to practice as a Registered Nurse (RN) in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States

Experience:

• Three (3) years of clinical nursing experience performing direct patient care with at least 2 years in an Inpatient setting on a medical-surgical unit, PACU, or higher acuity Inpatient unit (ICU, Step-Down, Telemetry, etc.) or home health (direct care) {clinical experience qualification may be determined by hiring manager/director.}
• Demonstrate knowledge of the case management, purchased referred care and utilization review
• Demonstrate knowledge of electronic health record systems.

MENTAL AND PHYSICAL EFFORT

The physical and mental demands described here are representative of those that must be met by an   employee to successfully perform the essential functions of this job.  Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Physical:

This position requires an individual of high energy who can maintain a long and flexible schedule to meet the management requirements. The physical requirements include; sitting at a desk for long periods of time, long periods of sitting in meetings; frequent sitting for intense work on a personal computer, frequent walking to interact with staff within the facility, frequent bending, kneeling, crouching, twisting, maintaining balance and reaching. Must be able to hear, speak and comprehend over the telephone and in person with others. Must have ability to lift, push and pull up to 50lbs frequently. Sensory requirements for position include prolonged ability for far, near, and color vision, depth perception, seeing fine details, hearing normal speech, telephone use and ability to frequently hear overhead pages. Must have ability of both hand manipulation in simple and firm grasping, fine manipulation, and use of keyboard.

Mental:

Uses independent judgment and analytical skills to make decisions that impact operations, finances, and customer service within the organization.  The incumbent must have the ability to perform in structured and unstructured environments and possess a keen attention to detail and propose practices/mechanisms to enhance customer satisfaction. Must have ability to continually concentrate, handle a high degree of flexibility, handle multiple priorities in stressful situation, demonstrate high degree of patience, adapt to shift work, work in areas that are close in crowded, frequently cope with high levels of stress, make decisions under high pressure, work alone, and occasionally cope with anger/fear/hostility of others in a calm way and manage altercations.

Environmental:

May frequently be exposed to chemical agents, extremes in temperature of humidity, occasional exposure to infectious diseases, dust, fumes, gases, hazardous or moving equipment, and loud noises.

Responsibilities

ESSENTIAL FUNCTIONS

• Collaborates with provider and nursing personnel to ensure admissions are conducted seamlessly and without delay of patient care.
• Collaborates with provider, nursing personnel and patient benefits coordinators that all admission documentation is complete and all referrals for third party resources are complete prior to the departure of patients.