Dept: Clinical Review
This role is offsite, work from home/Remote.
Responsibilities include providing clinical and educational support assessments, analysis, coordination of the quality and training management program, assisting in the divisional accreditation process, and conducting/assisting with internal and external audits.
Nursing Diploma or Associates Degree in Nursing required. Bachelor's degree in nursing (BSN) or related fields preferred. Registered Nurse with current unrestricted Michigan Registered Nurse license required. Five (5) years of experience in health-related fields required. Three (3) to five (5) years' experience with Care Management and/or Utilization Management. CM certification preferred.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
1. Responsible for educating staff in managed care as it relates to department programs, processes, and systems.
2. Conduct quality reviews on cases.
3. Develops, implements and updates training manuals reflecting new approaches to training, departmental and/or system process changes and InterQual criteria updates as needed.
4. Oversee and mentor new employees during the initial training program.
5. Work closely with the leadership team and subject matter experts external and internal to assess the learning environment and determine relevant resources for training.
6. Educate staff and external provider facilities in the clinical policies criteria and procedures of InterQual as well as an overview of the department, general functions, responsibilities, and department relationships with other departments.
7. Prepare all training materials and develop training packages with related materials assigned by leadership.
8. Participate in development, testing and implementation of new programs and systems as assigned.
9. Share performance information with operations and training management to determine next steps.
10. Coordinate administrative activities with the training supervisor and operations management, including class evaluations, updating files, class registration, scheduling classes, new hire system/software access, personnel information, and attendance management.
11. Coordinate and perform internal and external audits as required.
12. Travel may be required.
OTHER SKILLS AND ABILITIES
1. Effective analytical, verbal, and written communication skills.
2. Effective project management skills to create and execute work plans.
3. Ability to work independently and in a team environment.
4. Ability to manage multiple tasks.
5. Proficient in relevant PC applications (Share point, Care Advance, Microsoft Platforms – Excel, Word, Teams etc.).
6. Basic knowledge of ICD 10 and CPT Codes.
7. Member Health Record, VDA (Virtual Desktop), Care Advance.
8. Knowledge of local, state, and federal regulations (CMS, NCQA, PA60, HIPPA).
9. Ability to use clinical assessments and interventions.
10. Knowledge of effective communication techniques and theories.
11. Knowledge of utilization management and InterQual and/or MCG criteria.
12. Must be willing to act as a "change agent” on behalf of area and positively support the inception of new programs, systems, processes, software, and tools.
