Utilization Management Clinical Auditor and Trainer RN

We appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will help us potentially place you in a position that meets your objectives and those of the organization. Qualified applicants are considered for positions without regard to race, color, religion, sex (including pregnancy, childbirth and breastfeeding, or any related medical conditions), national origin, ancestry, age, marital or veteran status, sexual orientation, gender identity, genetic information, gender expression, military status, or the presence of a non-job related medical condition or disability (mental or physical).

KHS reasonably expects to pay starting compensation for the position of Utilization Management Clinical Auditor and Trainer RN in the range of $48.36 – $62.98 hourly.

• $5,000 RN Bonus

Our Mission.. Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system.

PRIMARY PURPOSE:
Under the direction of the Director of Utilization Management (UM), the UM Clinical Manager and reporting to the UM Outpatient Clinical Supervisor; the UM Auditor and Trainer RN is responsible for reviewing Utilization Management (UM) policy and guidelines to ensure staff compliance with policies. Responsibilities include ensuring coordination of services not only within inpatient and outpatient groups, but also between the groups and community. Perform audits on various project reports, Notice of Action notifications, and referrals for compliance. Responsible for reporting findings to management for review and possible corrective action. Provide recommendation for process improvement and assist with action plans for making those corrections. The Clinical Auditor and Trainer RN will work in a coordinated effort with UM Outpatient Clinical Supervisor(s), Manager of Health Services, and Business Analysts to ensure smooth, efficient and productive operations within the UM Department, as directed by the Director of Utilization Management. This position will work closely with the Chief Medical Officer and Medical Director(s) in the smooth and efficient operation of the referral and inpatient clinical decision-making process.

CLASS CHARACTERISTICS:
This position will provide technical support to a Knox-Keene licensed health maintenance organization (HMO) Utilization Management Department. The purpose of this position is to provide support to the UM Management team for auditing and analytics of the UM authorization process to ensure accuracy and quality as well as performing retrospective audits. Training for all on-boarding of clinical staff and development of defined and prescribed criteria for staff improvement in addition to providing one-on-one training to improve staff efficiencies will be major focus of the position.

SUPERVISES: NO

MAJOR DUTIES & RESPONSIBILITIES:

• Maintains knowledge of covered benefits for all programs.
• Shares information as necessary with appropriate UM Clinical Staff, Population Health Management and Health Education, Quality Improvement, Enhanced Care Management or Community Support Services.
• Maintains and updates authorizations in the core claims system to enable timely payment of claims.
• Keeps current with California Children’s Services benefits and guidelines for coordination of services.
• Train other UM staff as appropriate regarding use of all platforms and core adjudication system as it relates to UM processes;
• Maintain an effective, efficient, and confidential filing system both manual and electronic to allow easy retrieval and re-filing of department information.
• Develop and implement staff training for new and existing employees along with internal findings.
• Responsible for written and verbal communication with contract providers and internal KHS staff to promote timely coordination of care and dissemination of KHS policies and procedures.
• Assist the UM clinical staff in the review of claims and disputes for the accuracy and appropriateness of billed charges;
• In coordination with the UM Auditor and Analyst, perform audits of performance of UM Clinical Intake Coordinators and Social Workers and summarize and report the results of the audit to UM Management for process improvement;
• Perform periodic audits of inpatient and outpatient clinical decisions for appropriateness and accuracy of documentation;
• Assists in data collection and compilation, of various committee and quarterly reports.
• Maintains the confidentiality of records and reports for both the membership of KHS and the contract providers.
• Promote coordination with KHS Medical Director(s), Pharmacy and other departments and community partners, as appropriate, in making sound clinical decisions;
• Summarize and prepare necessary production reports for management;
• Performs other job-related duties as required;
• Adheres to all company policies and procedures related to employment and job Responsibilities.

REQUIREMENTS:
CORE COMPENTENCIES / KNOWLEDGE & SKILL REQUIREMENTS

• Lead by example to support a positive work environment that values patient advocacy, respectful listening, diverse expression of opinion and constructive conflict resolution;
• Adheres to KHS’s Code of Ethics and Business Conduct and all company policies; e.g., confidentiality, attendance, safety/security, use of equipment and technology, appearance and demeanor;
• Represent KHS in a positive manner to all members, caregivers, staff and external stakeholders;
• Demonstrate commitment to continuous improvement;
• Strong knowledge of acute chronic care nursing principles, methods and common treatments;
• Strong knowledge of common human diseases and usual and customary methods of treatments;
• Demonstrated knowledge of medical terminology;
• Ability to effectively evaluate medical records to determine appropriateness and necessity of care;
• Demonstrated knowledge of health care delivery systems;
• Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individual at all levels both inside and outside of KHS;
• Ability to use tact and diplomacy to diffuse emotional situations;
• Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards;
• Intermediate skills in Word and Excel with basic ability to enter data into and navigate through a database;
• Demonstrated ability to respect and maintain the confidentiality of all sensitive documents, records, discussions and other information generated in connection with activities conducted in, or related to, patient healthcare, KHS business or employee information and make no disclosure of such information except as required in the conduct of business;
• Demonstrated ability to commit to and facilitate an atmosphere of collaboration and teamwork;
• Self-directed, with proven ability to work independently with minimum supervision;

Demonstrated ability to multi-task in an interrupt-driven environment and complete assignments on a timely basis;

• Strong attention to detail; work accurately and at a reasonable rate of speed;
• Compliant with KHS policies and procedures; performs the job safely and with respect to others, to property, and to individual safety.

EMPLYMENT STANDARDS AND REQUIREMENTS

EDUCATION:

• Registered Nurse with an active, current, unrestricted California license.
• Bachelor’s Degree from an accredited school or equivalent in Nursing, Nursing Education, Health Administration, or related healthcare field is strongly preferred.

EXPERIENCE:

• Minimum of two (2) years full-time clinical experience in acute care, community health setting, public health nursing or chronic disease management required;
• Minimum of three (3) years’ experience in utilization review required;
• Internal KHS candidates must have reached UM RN Level 3 status;
• Prior experience in providing training, education, and auditing preferred.

KNOWLEDGE OF:

• Knowledge and familiarity with Managed Medi-Cal, Fee for Service Medi-Cal and Medicare benefits programs;
• Knowledge of MCG, InterQual or nationally recognized clinical guidelines required.
• Case Management/Care Coordination experience and CCM or MCG certification is a plus.
• Knowledge of Kern County Community resources for seniors and people with disabilities is a plus;

OTHER REQUIREMENTS:

• Valid California Driver License and proof of state required auto liability. Up to 10% Travel
• Bilingual English/Spanish Preferred

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis.

Salary : $48 - $63