Clinical UR Specialist

Requirements

• License /Certification
• Required: CA LVN license
• Education
• Preferred: Degree in Human Services areas of Social Work, Psychology or other health-related fields with medical terminology or equivalence.
• Required:
• Experience in extracting data from a medical record.
• Minimum of one year of clinical experience (acute care preferred).
• Preferred:
• Utilization review and/or coding experience.
• Department Specific Requirements:
• ED- Minimum of two years Case Management experience
• JOB RESPONSIBILITIES
• Essential
• Uses the results of quality of care/performance improvement activities to initiate changes in patient care practices:
• Collects clinical data for the RN to monitor quality and effectiveness of patient care.
• Identifies aspects of care that are important for quality monitoring.
• Participates in interdisciplinary teams.
• Performs Utilization Management to meet Case Management Goals:
• Reviews and records utilization review data to determine medical necessity for assigned caseload in a manner to ensure all inpatient records are current.
• Issues a non-certification letter as directed by the Case Management Committee.
• Informs the Case Management Team and attending physician of any questionable or denied cases resulting from the review of the onsite Medi-Cal reviewer, CMRI or private insurance companies. Initiates further action by following guidelines set forth in the Hospital Case Management Plan.
• Collaborates and communicates with the patient/resident, family, physician, and other health care providers:
• Makes referrals, including provisions for continuity of care.
• Facilitates and coordinates placement of patients in appropriate long-term care facilities.
• Facilitates arrangements for acute transfer to other acute facilities when indicated.
• Assists case management team with discharge planning services that can include coordination of equipment, home care, home health, and transportation services. Assists patients with information and reviews Advance Directives.
• Participates in Continuum of Care rounds.
• Accumulates information on community resources and links patients, families and staff to appropriate services.
• Performs special audits/reports as required by the Case Management Team.
• Displays attitude which supports Kaweah Health values and department efforts and teamwork.
• Addendum (essential for specific dept)
• PROGRAM LIAISON FOR INPATIENT REHABILITATION:
• Assumes responsibility for the implementation of each individual patient program.
• Assists the patient/family to become adequately oriented to their program.
• Enables the patient's program to proceed in an or

Benefits

Additional Information

Kaweah Health is a publicly owned, community healthcare organization that provides comprehensive health services to the greater Visalia area in central California. With more than 5,000 employees, Kaweah Health provides state-of-the-art medicine and high-quality preventive services in our acute care hospital, specialized health centers and clinics. Our eight-campus healthcare district has 613 beds and offers comprehensive health services across a broad continuum of care. It takes a special person to work for Kaweah Health. We serve a region where the needs are great, which makes the rewards even greater. Every day, we care for people facing unique challenges and in need of healing. Throughout it all, our focus is to make a difference, and we do - in the health of our patients, our loved ones, and our community. Benefits Eligible Full-Time Benefit Eligible Work Shift Day - 8 Hour or less Shift (United States of America) Department 8790 Case Management The Clinical UR Specialist works in collaboration with RN Case Management staff to gather clinical data to monitor quality and effectiveness of patient care. Assists with planning and execution of safe discharge plan in a timely manner while working in collaboration with the multi-disciplinary team.

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