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COC/Util Rev Coord RN conducts utilization review for in-house patients and those members at contracted facilities.

DEPARTMENT:Skilled NursingSCHEDULE:Part-Time regular, 20 hours per week, Vary shift, Monday, Friday - 8:30am - 5:00pm &Wednesday - 8:00am - 12:30pm w / weekend rotation.EDUCATION/LICENSE/CERTIFICATION:BSN or BA in health care related field preferred. Graduate of accredited school of nursing. Current California RN license. PHN preferred. JOB SUMMARY:Conducts utilization review for in-house patients and those members at contracted facilities. Assists in the discharge planning process.QUALIFICATIONS:Previous experience in an inpatient setting (usually 2 years). Previous experience utilization experience required (usually 1 year). Clinical expert in area of review preferred. Demonstrated knowledge of diagnostic codes.PREFERRED QUALIFICATIONS:Previous experience in an inpatient setting (usually 2 years). Previous experience utilization experience required (usually 1 year). Clinical expert in area of review preferred. Demonstrated knowledge of diagnostic codes. Provide clinical oversight for determination of medical necessity for admission to SNF & clinical denials based on medical necessity. Cross train to provide coverage for dept. manager. Cross train for SNF case manager which responsibilities include daily case management of patients while they are in the SNF, working with Kaiser team and contracted SNF team to coordinate needed care, discharge plans, equipment, education, follow-up medical appointments and family interaction and participation in plan of care.Cross train to SNF placement desk working with hospital discharge planners to find an appropriate SNF, secure bed and coordinate patient transfer with discharge planner. This consists of screening referrals for skilled determination, collecting needed documents for placement, coordinate obtaining bed with the SNF vendors and discharge planners, reports on PD placements. Additional responsibilities: create bi-weekly work schedule, reconciliation of Avoidable Days, utilization management reports & appeals processSKILLS TESTING: DUTIES:Conducts utilization review for in-house patients as well as those members who have admitted to contracted facilities. Conducts clinical reviews based on established treatment criteria. Reviews utilization patterns, identifies trends and problems areas for special studies. Assists other healthcare providers in the discharge planning process and triaging on alternative unit of care. Assists in collecting and assimilating clinical data to enhance the quality of services. Generates quality improvement results. Collaborates with physicians on clinical reviews, keeps them appraised of Kaiser clinical criteria. Reports and investigates unusual occurrences and questions inappropriate decisions based on their professional expertise. Interviews patients/caregivers regarding care after hospitalization. Counsels on Medicare and health care plan coverage. Coordinates referrals to appropriate agencies/facilities. OTHER DUTIES:Conducts utilization review for in-house patients and those members at contracted facilities. Assists in the discharge planning process. Conducts utilization review for in-house patients as well as those members who have admitted to contracted facilities. Conducts clinical reviews based on established treatment criteria. Reviews utilization patterns, identifies trends and problems areas for special studies. Assists other health care providers in the discharge planning process and triaging on alternative unit of care. Assists in collecting and assimilating clinical data to enhance the quality of services. Generates quality improvement results. Collaborates with physicians on clinical reviews, keeps them appraised of Kaiser clinical criteria. Reports and investigates unusual occurrences and questions inappropriate decisions based on their professional expertise. Interviews patients/caregivers regarding care after hospitalization. Counsels on Medicare and healthcare plan coverage. Coordinates referrals to appropriate agencies/facilities. Must have experience in skilled nursing facility nursing as well as an understanding of Medicare guidelines for skilled nursing facilities and skilled coverage for care.Case management experience strongly recommended..Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees. Consistently supports compliance and the Principles of Responsibility (KP�s code of conduct) by maintaining confidentiality, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal and State laws and regulations, accreditation and licensure requirements, and KP policies and procedures. In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Kaiser Permanente Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors.PLEASE NOTE: - Kaiser Permanente is an AA/EEO employer

DEPARTMENT: QualitySCHEDULE: Full time regular, 40 hrs/week, Day shift, Monday-Friday, 8:00 am to 5:00 pmEDUCATION/LICENSE/CERTIFICATION: Bachelors degree in health care administration, nursing, or public administration or related field required. Current California RN license (preferred) or other clinical licensure required. Master´s Degree preferred. Total Quality Management certification or Certified Professional of Healthcare Quality (CPHQ) preferred. BLS, ACLSJOB SUMMARY: Directs the Medical Center quality program for hospital and ambulatory sites, which may include one or more of the following: quality assessment and improvement, accreditation and regulation licensing, and compliance. Partners with the medical center executive leadership team and departments to ensure that the program effectively measures, assesses and continuously improves the quality of care and service provided. Manages, facilitates and supports activities related to accreditation, regulation and licensing issues for all health care sites and services across the continuum including, but not limited to: home health, ambulatory services, provider networks, hospital services and health plan. Translates various accrediting, regulatory and licensing agency requirements into action plans to achieve positive survey/audit reviews and renewed licenses. Oversees Medical Staff Services including credentialing and privileging, CME, GME and Medical Library.QUALIFICATIONS: Experience designing, developing, implementing clinical improvement programs. Significant experience (usually 5 years) in Quality Improvement in a health care setting. Previous Management experience required. Demonstrated knowledge of governmental and other regulatory standards, requirements, and guidelines related to quality improvement, such as The Joint Commission, NCQA, Knox-Keene Act, Federal HMO Act, CMS Conditions of Participation, Title 22,Cal-OSHA, HIPAA and Medi-Cal and Medicare regulations and standards. Strong working knowledge of ongoing monitoring techniques (including criteria development and statistical analysis); medical care delivery in hospital and outpatient settings; total quality management principles, tools, and techniques. Effective communication, negotiation and leadership skills. Must be able to work in a Labor/Management Partnership environment.PREFERRED QUALIFICATIONS: Previous management experience in nursing or other allied health professional experience preferred.SKILLS TESTING: RN Medication Math TestingDUTIES: Directs the medical center’s quality management program, which supports the organizational goals and priorities, as well as the requirements of regulatory and accrediting agencies. Provides oversight for the medical center wide involvement in quality improvements, communicate opportunities, results and priorities. Works closely with designated Chiefs of Service and Department Managers to address patient care issues with a goal toward resolution while maintaining confidentiality. Determines strategy for changing existing processes to meet regulatory requirements and translating external demands into program goals. Provides education and technical support to the Medical Center in developing, implementing and maintaining quality improvement activities. Identifies and implements practices to improve quality and service.Collaborates with leadership, departments, clients, TPMG, and community in designing processes, tools and templates that continually improve the quality, efficiency, service and effectiveness of care and service. Consults and participates in performance improvement teams using a variety of methodologies. Partners with Risk Management to reduce medical/legal liability through development of a program which links risk management activities with those of continuous quality improvement. Serves as a critical link in the identification and resolution of issues, which affect the organizational image. Develops and maintains relationships and effective communication with all levels of medical center physicians and staff in order to facilitate problem identification and resolution. Oversees preparation of periodic reports to the KFH/HP Board of Directors and coordinates completion of the Quality annual evaluation, workplan and program description. Supports the peer review process and partners with medical staff to assure process completion. Oversees Medical Staff Services including credentialing, privileging, CME/GME and library responsibilities. Consults on data analysis techniques and evaluates trends to identify potential opportunities for improvement. Manages staff and makes recommendations regarding the need for staff, space and other resources. Manages and resolves human resources and labor relations issues specific to management responsibilities. Develops systems, templates, tools and processes to identify and monitor indicators which best measure improvement in care delivery. Analyzes, interprets and makes recommendations to meet federal, state and local requirements. Identifies key accreditation, regulation and licensing issues and defines areas for improvement. Establishes mechanisms for proactive identification of regulatory issues and tracking of corrective action to minimize negative impact and maximize learning. Relays internal/external communication of information related to accreditation, regulation and licensing. Prepares for surveys and inspections, including educational forums, coordinating mock surveys and assessments assists in developing response plans. Coordinates Formal surveys for all regulatory and accrediting agencies. Interprets and assists in planning responses to new or changing regulations or standards. Collaborates with external regulators to develop standards, which promote high quality patient care and services. Serves as liaison to region, community groups, professional organizations, and licensing/regulatory agencies. Develops, implements, and meets the established financial goals. Monitors applicable budget, and identify and support solutions to reduce cost structure. In collaboration with TPMG, ensures development of a CME program which supports clinical quality goals, trended peer review findings and new technologies embraced by the INTC. Ensures the Medical Library resource supports the achievement of organizational goals through research and best practice identification. Strategically position library services to support the organization’s clinical quality goals and preventive health measures. Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions for salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees. Consistently supports compliance and the Principles of Responsibility (KP’s code of conduct) by maintaining confidentiality, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal and State laws and regulations, accreditation and licensure requirements, and KP policies and procedures. In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Kaiser Permanente Service Quality Credo, the KP Mission as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrated the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors.PLEASE NOTE: - Kaiser Permanente is an AA/EEO employer

Corvallis, Oregon - Utilization Nurse I

Provides utilization management/case management by coordinating resources, assuring appropriate use of community resources, support and service delivery through the components of case management/utilization management. Three (3) years nursing experience required with one (1) year of utilization review or case management experience preferred.A current unencumbered Oregon Registered Nurse License required.Experience and/or training in health care delivery systems and managed care required.Experience and/or training in insurance benefits including Medicare and Medicaid required.Experience and/or training in database management and statistics is preferred.Baccalaureate Degree in Nursing is preferred.

Part of Sunrise Health, MountainView Hospital is a full-service modern 250-bed facility in the heart of northwest Las Vegas. Here we offer a family-like culture and stress a team-based approach, aimed at continuing to achieve high levels of patient satisfaction. We are known for our low nurse-to-patient ratio and specialty adult and pediatric intensive care units, and were honored with a Service Excellence Award for womens health and maternity care. We currently have an opportunity for a full-time Quality Management Coordinator who will assume organizational responsibility for medical staff peer review functions and assigned quality improvement initiatives. The Coordinator will serve as team leader for selected quality improvement projects as assigned. In addition, the Coordinator will design and implement quality studies; perform medical record review for abstraction of data for core measures and/or clinical review for peer review and oversee ongoing professional practice evaluation (OPPE). Qualified candidates must have: Nevada Registered Nurse License Bachelors Degree in Nursing or health related field, Masters Degree preferred Professional in Healthcare Quality Certification preferred A minimum of three years recent experience in medical staff peer review/quality management preferred Experience with Microsoft Office, database management preferred Understanding of data management systems Intermediate computer knowledge and expertise At Sunrise Health were guided by a simple yet powerful motto, Another Sunrise. Another Miracle.. And while technology is at the forefront of everything we do, we havent forgotten that its our people who make miracles happen and help our patients heal. As part of our team, we provide you with a benefits package designed to meet your individual needs. Whether youre new to the area or a longtime resident, theres always something new to discover in Las Vegas. For more information please contact Pam at Pamela.Hulbert@hcahealthcare.com or visit our website at www.sunrisehealth.jobs/mountainview to learn more about our opportunities and all that Las Vegas has to offer.Sunrise Health is an equal opportunity employer.

Become a Cedars-Sinai Employee!

Hours: 8am - 4:30pm Days: Monday - FridayShift Type: DayWeekends: None Job Description: Cedars-Sinai Health System has an opening for a RN, Supervisor Case Review. The Case Review Supervisor will be responsible for the day to day oversight of the Peer Review Process. The supervisor will review correspondence and assist case review coordinators with routine process questions. The Supervisor must demonstrate initiative, resourcefulness and problem-solving skills in applying a detailed knowledge of the responsibilities, functions and underlying management structure of the department and of the larger Health System in organizing and prioritizing work, establishing procedures and systems and ensuring the orderly and timely flow of business. The Supervisor must possess a full understanding of the confidentiality requirements to effectively and legally communicate practitioner related issues. The supervisor will communicate to the Patient Safety Manager all concerns and issues of a non routine nature or potential safety issue. In addition, the supervisor will be responsible for coordinating the Ongoing Professional Practice Evaluation (OPPE) for the medical staff. The Supervisor will have oversight of the Case Review Coordinator who will focus on identifying professional practice trends that impact quality of care and patient safety. The Supervisor will utilize expert clinical knowledge and experience to collaborate with the Case Review Coordinator using the Medical Center and Department specific criteria. Education and Work Experience Preferences: Educational Requirements:Bachelors Degree preferred and course work in healthcare related field preferred.License/Certification/Registration Requirements:Current active licensure as Registered Nurse in California required; Certified Professional in Healthcare Quality preferred

The Chief Quality Officer is responsible for planning, administration, and monitoring of consistent readiness of all quality management, regulatory requirements, and quality improvement processes. The Chief Quality Officer will oversee and coordinate all hospital efforts to monitor and maintain compliance with all regulatory, State, Federal government, and Joint Commission on Accreditation of Healthcare Organization standards. The position reports directly to the CEO.Qualifications Education:• Graduate of an accredited school of nursing.Experience:• Minimum of three years in an acute care facility and demonstrates a clear working knowledge of general hospital operations, JCAHO, OSHA, Medicare COP, and state requirements. • Minimum of two years experience in Quality Management required.• Must have coordinated JCAHO preparation and participated in State and CMS surveys within past three years.Certifications / Licenses:• Current state Nurse license

Performs utilization management activities, discharge planning, and care coordination across the continuum of care in collaboration with the physician and other members of the health care team.

DEPARTMENT: Resource Management SCHEDULE: On-Call, 0 hours per week, Day Shift. 8:00am to 4:30pm. Variable weekdays and hours to support needs of the department. Includes every other third weekend. EDUCATION: BSN or BA in health care related field or Diploma/Associate Degree Nursing (ADN) with comparable years of experience required. Masters Degree preferred. Graduate of accredited school of nursing. LICENSE/CERTIFICATION: BLS Certification and current California RN licensure required. JOB SUMMARY: Performs utilization management activities, discharge planning, and care coordination across the continuum of care in collaboration with the physician and other members of the health care team. QUALIFICATIONS: Experience (usually 2+ years) in direct patient care delivery and management. Demonstrated experience in utilization review, case management, and discharge planning preferred (usually 2+ years). Knowledge of the Nurse Practice Act, The Joint Commission, DMHC, CMS, NCQA, HIPPA, ERISA, EMTALA and all other applicable federal/state/local laws and regulations. Demonstrated strong communication and customer service skills, problem-solving, critical thinking, and clinical judgment abilities. Fundamental word processing and computer navigation skills, and the ability to interpret and use analytic data in day to day operations. Knowledge of healthcare benefits associated with various business lines (Medicare/KPSA, Commercial/KFH, Medi-Cal, Federal, etc.). DUTIES: Utilization Management: Performs daily preadmission, admission, and concurrent utilization reviews using guidelines, institutional policies/procedures, and other information to determine appropriate levels of care and readiness for discharge. Escalates utilization and system problems which have not been resolved at the local level to the next level (RM/UM Director, CCL, DHO, etc.), immediately. Monitors the progression of the plan of care and facilitates discussions with the multi-disciplinary teams. Educates other healthcare team members on utilization and cost containment initiatives. Collaborates with and provides information to patients, families, physicians, and staff regarding the provisions of care. Incorporates and counsels on the correct and consistent application, interpretation, and utilization of member health care benefits (including transition of care). Discharge Planning: Ensures continuity of care through communication in rounds and written documentation, level of care recommendations, transfer coordination, discharge planning and obtaining authorizations/approvals as needed for outside services for the patient. Develops, evaluates, and coordinates a comprehensive discharge plan in conjunction with the patient/family, physician, nursing , social services, and other healthcare providers and agencies. Performance Improvement: Monitors care processes to provide cost-effective implementation and evaluation of utilization management and patient care activities, initiatives, and protocols. Participates in the development and implementation of guidelines, preprinted physician orders, carepaths, etc. for patient care. Identifies and assists in the implementation of opportunities for cost-savings and improvements in the quality of care across the continuum. Develops, collects, trends, and analyzes data relevant to the utilization of healthcare resources including avoidable/variance days, readmissions, one-day stays, DRGs, LOS, etc. Participates in the development, implementation, communication, maintenance and monitoring of local UM Workplan initiatives. Administrative and Regulatory: Shares accountability with the UM Manager for planning, developing, and managing the department budget. Participates in interviewing, makes hiring recommendations, orients and provides on-going supervision of support staff. Provides input into the performance evaluations of team members. May plan and control work assignments and special projects of team members. Assists in developing, implementing and maintaining utilization management policies and procedures. Conducts UM, care coordination, and discharge planning activities according to all applicable regulatory requirements (see qualifications). Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees. Consistently supports compliance and the Principles of Responsibility (KP´s code of conduct) by maintaining confidentiality, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal and State laws and regulations, accreditation and licensure requirements, and KP policies and procedures. PLEASE NOTE: Kaiser Permanente is an AA/EEO employer.

Reporting to the Risk Manager, this position leads and coordinates improvement activities throughout Overlake Hospital for successful accrediting, licensing, and certification surveys (e.g., Joint Commission, Dept of Health, Centers for Medicare/Medicaid Services). Develops and implements systems and processes to sustain survey readiness, including the development and implementation of staff education forums and ongoing internal competency/preparedness reviews. We are proud to be one of the recipients of the 2009 HealthGrades Patient Safety Excellence Award. This award is granted to the top 5 percent of all hospitals in the U.S.This position requires a Bachelors degree, else an Associates degree in a clinical area plus 2 years related experience. Masters preferred. Current licensure as appropriate to profession is required. Also requires 3 years experience in an inpatient setting, with specific knowledge of hospital regulatory and accrediting standards. CPHQ or CQP certification strongly desired.

Join our unique, personalized approach to healthcare at University Hospitals.

University Hospitals (UH) is a community-based health care system which serves patients at more than 150 locations throughout Northern Ohio, including seven wholly owned and four affiliated hospitals. Committed to advanced care and advanced caring, UH encompasses the regions largest network of primary care physicians, outpatient centers and hospitals. The network also offers specialty care physicians to treat almost every disease and condition, skilled nursing, elder health, rehabilitation and home care services, and occupational health and wellness. University Hospitals is the second largest private sector employer in Northeast Ohio and is within the top five largest private sector employers in the state of Ohio. Detailed Position Description This position will be responsible for clinical systems expertise focused on quality initiatives. The Application Analyst will serve as a bridge between the Quality and end-users of the Eclipsys application, participating in software design, implementation, testing, reporting and ongoing support. Participates with the implementation team and clinical subject matter experts, in an enterprise design which will represent an improved clinical workflow and eliminates current state paper-based processes, as applicable while incorporating Quality Outcomes. Position Requirements 5+ years in a clinical/healthcare setting Strong preference for experience in healthcare quality initiatives (TJC, CMS) Must be able to communicate with a wide variety of end users, with varying skill levels and function effectively in a fast-paced environment and meet deadlines. Excellent analytical and problem solving skills required. Moderate skills in MS Office suite. Education Requirements Bachelors degree in a Health related or Information Systems field required. License/Certification Requirements RN, RT, RD, PT, PharmD or other health care professional licensure. Additional Details Employment Status Regular Full Time Shift Days

The Director, Post Acute QA PI/Education is directly responsible to lead, develop and implement effective methods to: assess and ensure quality assurance/process improvement initiatives; oversee clinical staff orientation, education and competency assessments; monitor and assure compliance with regulatory standards; interface with IT staff for effective design and use of electronic medical record and billing software; and oversee effective case management practices for Summa´s Home Care, Hospice of Summa, Summa´s Maternal Touch and Summa´s Home Infusion.The Director, Post Acute QA PI/Education serves as a resource to Summa Health System merged and/or affiliate hospitals post acute programs in sharing, developing and implementing: quality assurance/process improvement methods and practices; staff orientation, education and competency plans and presentations; regulatory compliance standards and updates.Requires a Masters degree in Nursing, Business, Hospital Administration, or other related field of study and a current license to practice nursing in the State of Ohio.Three (3) years QI/Education experience in a homecare/hospice environment to include two (2) years of leadership experience required.