RN/LPN Care Oversight Coordinator
Location: Clearwater, FL
Company: Community Health Solutions
The Care Oversight Coordinator is a Registered Nurse or Licensed Practical Nurse who provides oversight of clinical information and internal processes to determine medical necessity of treatment collaborate with care coordinators for referral to case management and communicate with Peer Reviewer when necessary for timely medical necessity review. This position requires licensure in a health discipline that allows the professional to conduct an assessment independently within the scope of practice of their discipline.
Essential Duties and Responsibilities:
- Serves as a facilitator to providers for resolution of provider concerns, complaints and grievances.
- Maintains and ensures the confidentiality of all information collected during the review process.
- Participates in medical necessity, URAC, clinical and quality training programs.
- Identifies need for referral to case management services based on established referral criteria or individual care need identified during interaction with Members or providers.
- Communicates program parameters with providers and members.
- Establishes medical necessity of service requests based evidence based guidelines, community standards, client guidelines or clinical expertise.
- Maintain a positive professional and respectful attitude with peers, and clients.
- Determine appropriateness of requested inpatient and outpatient services as defined by the Care Management Program.
- Determine appropriateness of on-going service request as defined by the Care Management Program.
- Follows established policy and procedures for timely medical necessity review, escalation, Peer Review and appeals meeting all state, URAC and applicable regulatory guidelines.
- Communicates with physicians, patients and family members regarding utilization management process, goals and expected outcomes.
- Monitors clinical status and internal quality check guidelines to conduct concurrent medical necessity review.
- To determine and monitor appropriate discharge plans for all approved services.
- Maintains appropriate level of experience and/or education to perform job responsibilities.
- Able to provide patients and providers with information regarding available Case Management, Disease Management or Disease Education programs.
- Analyzes utilization data for department to understand trends and improvement or process opportunities.
- Adheres to the policies and procedures of Community Health Solutions
- Maintains strict confidentiality of client, company and personnel information
- Demonstrates a strong commitment to the mission and values of the organization
- Adheres to company attendance standards
- Performs other duties as assigned
- Strong organizational and interpersonal skills
- Excellent written and verbal communication skills
- Detail oriented
- Ability to multi-task and work independently
- Excellent customer service skills
- A minimum of three (3) years of Utilization Review / Utilization Management experience is strongly preferred
- Demonstrated knowledge of utilization management and URAC principles.
Education and/or Experience:
- A Bachelor’s degree or equivalent experience in healthcare is strongly preferred.
- A minimum of three (3) years clinical experience.
Certificates, Licenses, Registrations:
Current RN or LPN licensure in Florida and other states where business is conducted
Proficiency using software programs such as MS Word, PowerPoint, Excel, and Outlook. Ability to type care coordination documentation directly into the system.
Environmental Factors/Physical Demands:
Work is performed in an office environment. While performing the duties of this job, the employee is regularly required to have the ability to maintain active customer and employee communication; access, input and retrieve information from the computer system; enter alpha-numeric data into a computerized system often while listening on the telephone. May be subject to repetitive motion such as typing, data entry and vision to monitor.
To apply, please forward resume to firstname.lastname@example.org
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