Registered Nurse - UTILIZATION REVIEW PROGRAM MANAGER

SEARHC is a non-profit health consortium which serves the health interests of the residents of Southeast Alaska. We see our employees as our strongest assets. It is our priority to further their development and our organization by aiding in their professional advancement.

Working at SEARHC is more than a job, it’s a fulfilling career. We offer generous benefits, including retirement, paid time off, paid parental leave, health, dental, and vision benefits, life insurance and long and short-term disability, and more.

This position oversees the day-to-day requirements of Utilization Management & Review, authorizing acute and sub-acute admissions at the Southeast Alaska Regional Health Consortium (“SEARHC”) Mount Edgecumbe Medical Center. This position works intensively with advanced systems to track and trend denials, build models for documentation improvement plans, and coordinate with all areas and levels of the hospital. This position works closely with the provider community to improve clinical documentation, and with administration to ensure appropriate utilization of hospital resources.

Under general supervision, provides professional assessment, planning, coordination, implementation, and reporting of complex clinical data. Maintains compliance with regulations affecting utilization management. Provider communication and behavior change can be challenging; this individual must be a master communicator and change agent. Clinical background required, as this position will be required to read, rapidly synthesize, and narrate a clinical event to patients’ third-party coverage for accurate and timely authorization and reimbursement. Must be able to understand and manipulate advanced systems and work with and synthesize large relational data sets, providing descriptive/predictive/prescriptive analytics to modify facility operational behavior.

$41.83-$53.45/hr DOE

• Reviews patients’ records and evaluates patient progress. Performs prospective (admission), concurrent, and retrospective reviews and reconsideration reviews/appeals; collects data to determine appropriateness of admission and extended stay; records and transmits assessment findings, evaluations, and review decisions; completes reports on review decisions and activities; promotes quality improvement by identifying and referring issues affecting patient quality of care; insures compliance with Revenue Cycle billing processes, monitors the audit of cyclic reviews; certifies admission based on medical necessity.
• Analyzes patient records and participates in interdisciplinary collaboration with professional staff and Care Coordination team. Consults with the Care Coordination team regarding the level of nursing care and collaborates with other departments in the evaluation of projects affecting discharge plans.
• Facilitates educational programs and advises physicians and other departments of regulations affecting utilization management.
• Coordinates and attends all Quarterly Utilization Review meetings and provides information relative to the review process and any identified problems. Responsible for the agenda and meeting minutes; policy oversight with committee approval; performs any reviews and studies as delegated by the committee; serves primarily as a liaison between the hospital and any peer review organization and/or any other review agencies.
• Documents review information. Communicates results to claims adjusters (i.e. Revenue Cycle). Enters billing information as appropriate; prepares information for notification letters from providers and employees. Receives and processes requests for appeal of denials; responds to complaints per UR guidelines; maintains Utilization Review and appeal logs.
• Supports clinical improvement activities of SEARHC by providing quality review; records and reports all information within scope and authority.
•  Performs any administrative duties; receives, logs, and files a variety of reports, charts, client interactions and other documents; performs other duties as assigned or required.

Education/Experience/Certifications

• Bachelor’s degree in Nursing
• Five (5) years clinical care or nursing experience or an equivalent combination of education and experience AND two (2) years’ experience in Utilization Review
• A valid, current, full, and unrestricted RN license in the State of Alaska OR licensed in another State and obtain Alaska license within 6 months of hire
• Utilization Review certification through the ABQARP or equivalent such as CMCN.

Knowledge, Skills & Abilities:

Knowledge

• Advanced knowledge in conducting and reviewing medical record for medical necessity.
• Working knowledge of ICD-10 and CPT coding.
• Working knowledge of regulations as set forth by The Centers for Medicare Medicaid Services, and the State of Alaska Department of Health and Social Services (“DHSS”)
• Efficient in MS Word and Excel

Skills

• Skill in providing effective nursing care, assessing patient situations and taking effective courses of action.
• Strong technology, systems, and analytical skills

Abilities

• Ability to communicate effectively with providers, staff, and patients.
• Strong written and oral communication skills.
• Strong organizational skills.