Clinical UR Specialist

Kaweah Delta Health Care District; Visalia (CA); On-site; USD 65,000 - 85,000; Full time

Job summary

Kaweah Health in Visalia, CA seeks a Clinical UR Specialist to support RN Case Management. You will collect clinical data, monitor quality measures, and assist with safe discharge planning in collaboration with a multidisciplinary team.

The role emphasizes utilization management, documentation of medical necessity, and coordination of care with patients, families and providers. Experience in case management is preferred.

Qualifications

• Experience extracting data from a medical record.
• Minimum of one year of clinical experience (acute care preferred).
• Preferred: utilization review and/or coding experience.
• ED: minimum two years Case Management experience.

Responsibilities

• Uses quality of care results to initiate changes in patient care practices and collect clinical data for RN review.
• Performs Utilization Management to determine medical necessity for the caseload and ensure inpatient records are current.
• Reviews records for admission and continued stay using InterQual criteria for appropriateness of care.
• Collaborates with patients, families, physicians and other providers to coordinate discharge planning and long-term care placements.

Skills

Data extraction from medical records

Clinical experience

Interdisciplinary collaboration

Education

Degree in Human Services fields (Social Work, Psychology or related) with medical terminology

Tools

InterQual Severity of Illness

Intens ity of Service

Job description

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.

Benefits Eligible

• Full-Time Benefit Eligible

Work Shift

• Day - 8 Hour or less Shift (United States of America)

Department

• 8790 Case Management

The Clinical UR Specialist works in collaboration with RN Case Management staff to gather clinical data to monitor quality and effectiveness of patient care. Assists with planning and execution of safe discharge plan in a timely manner while working in collaboration with the multi-disciplinary team.

QUALIFICATIONS

License /Certification

• Required: CA LVN license

Education

• Preferred: Degree in Human Services areas of Social Work, Psychology or other health-related fields with medical terminology or equivalence.

Experience

• Required:
• Experience in extracting data from a medical record.
• Minimum of one year of clinical experience (acute care preferred).
• Preferred:
• Utilization review and/or coding experience.

Department Specific Requirements:

• ED- Minimum of two years Case Management experience

JOB RESPONSIBILITIES

Essential

• 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 in a manner to ensure all inpatient records are current. 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 as indicated. Reviews medical records for admission and continued stay utilizing InterQual Severity of Illness and Intensity of Service for appropriateness of the admission, continued stay, and utilization of resources. Must also review all cases transferred in and out of special/intensive care areas using specific criteria. Participants in Sub Committee reviews as designated. 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 of the onsite Medi-Cal reviewer, CMRI or private insurance companies. 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: Makes referrals, including provisions for continuity of care. 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 that can include coordination of equipment, home care, home health, and transportation 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. Meets OSHA and TJC standards for safety. Reviews appropriate sections of Environment of Care Manual and MSDS/Infection Control Manual annually. Has had a current TB skin test. Reviews and complies with department safety plan. Safety Test completed annually prior to annual evaluation. Attends Kaweah Health mandatory safety in-services. Displays attitude which supports Kaweah Health values and department efforts and teamwork.

Addendum (essential for specific dept)

• PROGRAM LIAISON FOR INPATIENT REHABILITATION: Assumes responsibility for the implementation of each individual patient program.
• Assists the patient/family to become adequately oriented to their program.
• Enables the patient's program to proceed in an or