Quality & Case Review Registered Nurse

Tuba City Regional Health Care Corporation (TCRHCC); Tuba City (AZ); Sur place; USD 90 000 - 120 000; Plein temps

Résumé du poste

Tuba City Regional Health Care Corporation (TCRHCC) seeks an experienced Registered Nurse for the Case Review role to analyze medical staff quality and performance data, coordinate data collection, and support peer review activities. This position aims to improve patient safety and care standards through a non-punitive, learning-focused process.

You will manage ongoing professional practice evaluations, assist with the Peer Review Committee, and collaborate with physicians and staff to resolve

Qualifications

• Bachelor’s degree in nursing and Master’s Degree in Business Administration or other Master’s degree in healthcare.
• A valid, current, full and unrestricted Professional Nursing License to practice nursing in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States
• Five (5) years of supervisory experience in discharge planning, case management, or utilization review in an acute-care health care setting or related healthcare clinical leadership

Responsabilités

• Reviews patient records and clinical documentation to assess the appropriateness and necessity of healthcare services, ensuring quality and cost-effectiveness of care.
• Resolves informal/formal complaints and grievances within jurisdiction and refers appropriately to a higher level of management if needed.
• Review patient records, thoroughly examine patient charts, clinical documentation, and billing information to assess the appropriateness and necessity of services provided.
• Perform chart reviews to identify quality, timeliness, and appropriateness of patient care.
• Refer cases as appropriate to physician advisors for review and determination.
• Requires experience in performance improvement methodologies; quality measurement; and data analysis using statistical principles.
• Prior experience in hospital or clinical management preferred.
• Requires computer knowledge.
• Windows application: Skilled in the use of select Microsoft Office Applications, e.g. Word; Excel and PowerPoint or other database management applications.
• Requires strong written and verbal communication skills and the ability to work effectively with all levels of the organization and with members of the medical staff.
• Requires strong public speaking skills and the ability to deliver effective presentations and education to large groups of physicians and staff.
• Requires ability to prioritize multiple projects and the flexibility to accommodate changing priorities.
• Effectively communicates and coordinates processes to assure the continuity of patient care to outside providers and promote patient advocacy among Navajo Area Indian Health Services/Service Units, and Federal and State entities.
• Develops and implements policies and procedures regarding case management eligibility, alternate resource programs, referral/notification process, interdepartmental relationship and responsibilities; promote patient access to the appropriate level of care, prevent over or under utilization of resources, maximize the use of alternate resources, and supports continuity of care.
• Assists with review, research, and decision of first level appeal process with Purchase Referred Care
• Provides clinical expertise, skills, and behaviors appropriate to the population(s), served, and based on specific criteria and/or age-specific considerations. Supports, educates, and oversees the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation enhancement guidelines for selected patient populations.
• Collaborates with the Physician Advisor or designee in leading and facilitating the Utilization Review Committee, develops and interprets reports (i.e. statistical, financial, trends), provides data for the PI Committee and submits reports, as required, on outcomes, clinical quality documentation and insurance medical necessity criteria.

Connaissances

Communication

Ethical standards

Detail oriented

Data analysis

Report writing

Microsoft Office

Formation

Bachelor’s degree in nursing

MBA or master’s in healthcare

Outils

Excel

PowerPoint

Database software

Description du poste

Tuba City Regional Health Care Corporation (TCRHCC) seeks an experienced Registered Nurse for the Case Review role to analyze medical staff quality and performance data, coordinate data collection, and support peer review activities. This position aims to improve patient safety and care standards through a non-punitive, learning-focused process.

You will manage ongoing professional practice evaluations, assist with the Peer Review Committee, and collaborate with physicians and staff to resolve