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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.

You can achieve more at HCA West Florida. With 16 hospitals located throughout Tampa, St. Petersburg, Sarasota and the greater Orlando area, you´re sure to find the one workplace that does more for you - personally and professionally. Our team is made up of 15,000 individuals united by one purpose: to make the most of each other´s talents. That means you´ll have the support and the resources you need to pursue your goals. Join us here for a rewarding future that focuses on what matters most to you.View Northside Hospital and Tampa Bay Heart Institute Career Video: http://www.maddash.net/videos/northside/ Join us at Regional Medical Center Bayonet Point, part of the growing HCA West Florida hospital system. Our suburban Gulf Coast location is just 45 minutes from the vibrant city of Tampa. With 290 beds, we offer a spectrum of services seldom found in a small community setting. In addition to our acclaimed Heart Institute, some of our most interesting specialties include:* Accredited Chest Pain Center* JCAHO Stroke Program* Cancer Care Center* Neurosurgical Services* Advanced Same-Day Surgery* Regional Infusion Center* Wound Care* Accredited Hyperbaric Oxygen Treatment Program* Regional Center For Orthopedics & Surgical ServicesAs an integral part of the nation´s largest healthcare system, HCA West Florida hospitals give employees more support than you can possibly imagine. Each of our 13 hospitals is fully equipped with the latest technology and the greatest resources, so you can provide the highest quality care possible. In return for your dedication, we offer a generous benefits package, tuition reimbursement and professional learning opportunities. Plus a lot of extra incentives that make life much more rewarding. To learn more about Regional Medical Center Bayonet Point please visit: www.MoreCareerChoices.com - High School Graduate or GED required. - 2-3 years related healthcare experience required.- Notary preferred.- Ability to handle multiple priorities- Demonstrated skills in organization, verbal and written communications, customer service, math, analysis, reading, following instruction, basic computer usage.- Provides administrative support to the Director of Utilization Management and Case Management Department, as needed, to facilitate and expedite the functional duties and responsibilities.

Brigham and Women´s Hospital is more than a healthcare institution - it´s the birthplace of legendary medicine and one of America´s most respected and innovative hospitals.

For 150 years, we´ve been reinventing not only modern healthcare, but healthcare careers as well. Here you´ll find an atmosphere where collaboration and teamwork among physicians, nurses, technicians, staff and management is the norm, not the exception. Our passion for patient care and innovation leads to an ethic of mutual respect and camaraderie that permeates everything we do. In fact, we´ve been recognized by US News and World Report as a top hospital for 11 consecutive years.Brigham and Women´s Hospital is an Equal Opportunity Employer. Qualified applicants are considered for positions without regard to race, color, religion, sex, national origin, age, marital status, sexual orientation, status as a disabled veteran or a Vietnam Era veteran or the presence of a disability where otherwise qualified.GENERAL SUMMARY/ OVERVIEW STATEMENT:* The Resource Specialist (Financial RS) for outpatient, financial and reimbursement services acts as an expert resource to the Care Coordination Team (CCT), medical staff, nursing staff and other hospital departments to clarify regulatory rules and requirements of all third party payers. * Supports the clinical work of outpatient based Care Coordinator and the clinical denials processes. * Financial RS acts as a liaison between internal staff and external payers. * Financial RS maintains and monitors the reporting and record keeping computer systems for the utilization and outpatient CCRN functions.Day ShiftQUALIFICATIONS:* Bachelor´s degree preferred* Requires medical terminology* Requires proven outstanding communication, customer service and organization skills* Requires experience in a health care setting* Experience in Utilization Review preferred* Bilingual (English/Spanish) preferredSKILLS/ ABILITIES/ COMPETENCIES REQUIRED:* Excellent communication and organizational skills* Orientation to detail to insure accuracy a must* Computer literacy, Windows environment, word processing, spreadsheet, database management* Knowledge of medical terminology, managed care concepts and community organizations.* An independent yet team oriented person is crucial for care coordination process.* Strong analytical skills* Ability to work in a fast paced environment and to constantly change priorities* Ability to maintain a high degree of confidentiality* Strong interpersonal skills; must work closely and cooperatively with physicians and other health care professionals* Ability to work independently, make decisions, and to exercise appropriate judgment in setting priorities* Familiarity with the BWH/BICS network, Microsoft Word, Excel and Access is a plusWORKING CONDITIONS:* Works in a busy and, at times, stressful hospital/office environment.* Must be able to work well independently and in a multidisciplinary group. * Must be flexible.

Vanderbilt University Medical Center, a Magnet recognized organization and internationally respected leader in medical education research and patient care, enjoys a reputation for excellence unlike any other healthcare facility. An important part of that is the high regard we – and our patients – have for our staff. If you want a career where your knowledge is respected and your voice heard, come to Vanderbilt.We are currently seeking qualified candidates for the following position: Utilization Management Specialist, Utilization ManagementThe Specialist will facilitate optimal reimbursement through accurate certification and complete chart documentation. Conduct concurrent admission and continued stay reviews based on utilization review criteria. Refer and consult with the case manager and social worker to promote appropriate continued stay or discharge in the absence of definitive documentation and/or review criteria to support hospital stay. Basic Requirements: This position requires a graduate of an accredited LPN or RN program and 1 year of directly related experience (i.e., UM, DRG or Coding experience). The candidate must be a Registered Nurse or Licensed Practical Nurse in the state of Tennessee. UM experience required. Must be proficient with computers and various software. Experience with Interqual inpatient criteria is preferred. Additional Information: This is a full-time position working 40-hours per week, 7:30am – 4:00pm. Days of the week are flexible and include weekends. Background screens will be performed and education will be verified prior to employment. Please be prepared to provide required information and/or documentation.Vanderbilt is a smoke-free workplace in compliance with the Non-Smoker Protection Act, Tennessee Code Annotated 39-17-1801-1810. In accordance with that law and Vanderbilt policy, smoking is prohibited in all enclosed areas on Vanderbilt property.

Vassar Brothers Medical Center is a 365 bed facility that has been serving New York´s Mid-Hudson Valley since 1887.

The utilization management coordinator supports the clinical resource management team by providing clinical data to insurers, evaluating and, if appropriate, contesting payment denials for clinical reasons and collaborating with financial staff on billing and contract issues. He/she also acts as a resource person for case managers to help interpret criteria on severity of illness/intensity of service and appropriateness for acute level of care.Responsibility 1 Exchange of information with insurers Responsibility 2 Denials Management Responsibility 3 Clinical Liaison to Finance Staff Responsibility 4 Guidance to Case Managers Responsibility 5 Professional DevelopmentHealth Quest is the Mid-Hudson Valleys largest healthcare system providing the highest quality care across a broad spectrum of services. Offering the full range of hospital services, pre-hospital emergency care, homecare and nursing home care, the Health Quest system provides immediate and caring service to the one million people who reside in the New York counties of Columbia, Dutchess, Ulster, Orange, Putnam and northern Westchester. Our hospitals include Vassar Brothers Medical Center, Northern Dutchess Hospital, and Putnam Hospital Center.Vassar Brothers Medical Center is a 365 bed facility that has been serving New York´s Mid-Hudson Valley since 1887. Located on the banks of the Hudson River, Vassar Brothers has established centers of excellence in cardiac services, cancer care and women and children´s health services.RN with Bachelor´s degree in health care. Preferred min 3 years experience in utilization management.

Job Title: Resource Utilization Management Director Position Summary:Manages various Continuing Care departments as assigned, which may include 24 hour and/or multiple location departments. Plans, organizes, directs, evaluates, and coordinates services across the continuum of care within a Service Area, a single medical center or a Regional service. Oversees utilization in continuing care programs. Partners with the Hospital discharge planning and social needs of member population.Responsible for establishing, implementing and maintaining the components of the Resource Management process that is focused on the achievement of satisfactory patient outcomes within specific timeframes through the appropriate utilization of available internal and external resources. Accountable for providing oversight of the utilization management functions within the organization as directed by its policies and procedures.Coordinates with the Hospital and appropriate Hospital staff to provide for the seamless transition of patients across the continuum of care. Works with the Hospital and the Medical Group staff developing strategic plans, providing quality care, cost effective services which are aligned with federal, state, and local regulations. Represents Health Plan for Hospital operations.Education/License/Certification: BSN or BA in health care related field required. Master´s degree preferred. Graduate of accredited school of nursing. Current California RN license required. BLS required.Qualifications: Substantial experience in-patient care (usually 8 years). Progressive management experience required (usually 5 years). Demonstrated knowledge of Knox, Keene Act, Federal HMO Act, Nurse Practice Act, JCAHO, and all other local, state, and federal regulations. Demonstrated strong interpersonal communication skills.Duties: Organizes, plans, directs and coordinates the Resource Management process assuring that the organizational goals and objectives are met. Directs development and implementation of quality and utilization standards across the Hospital continuum of care to ensure coordinated plans of treatment, customer focused delivery of services, and cost effective utilization of necessary services. Ensures compliance with administrative, legal and regulatory requirements of the Health Plan contract and governmental and accrediting agencies. Oversees the development of department standards as identified by regulatory agencies, including The Joint Commission, NCQA, CMS, DHS and DMHC. Maintains a state of continuous regulatory readiness Communicates regulations to the healthcare team and implements operational processes as a result. Maintains oversight of the concurrent and retrospective inpatient reviews and appeal process.Collaborates with other Service Directors in identifying and implementing innovative models and best practices, emphasizing service improvements and cost reductions. Develops services that achieve a high level of customer satisfaction with emphasis on customer service and highest standards of quality and innovation. Utilizes research data to implement clinical changes and the delivery of patient care and member services. Evaluates processes and makes recommendations to improve resource management systems and patient care outcomes across the continuum. Presents Executive Team with ongoing, reliable information about the treatment and patient flow throughout all levels of care. Leads the way in providing data that supports the processes of case management and demonstrates quality patient outcomes. Demonstrates competency in the assessment, range of treatment, knowledge of growth and development and communication appropriate to the age of the patient. Plans, organizes and directs all activities within areas of responsibility. Responsible for the efficient utilization of resources within and the effective customer service given by the department. Provides clinical and administrative direction to the staff. Responsible for maintaining a process for the ongoing education and competency and development of staff as a group and individually. Manages and resolves human resource, labor relations, employee, and department safety and risk management issues.Participates in region wide peer group and leadership activities to drive consistency of operations and performance improvement. Develops and manages systems and relationships with outside vendors; contract and quality oversight with external vendors.Develops budget and resource allocations for areas of responsibilities. Manages the financial performance and identifies and implements appropriate strategies to reduce costs and improve quality of care and services. Focuses on prevention/intervention and identification if issues/problems prior to their impact on operations and patient care; recommends and develops new programs for specialized patient populations to improve quality and effect improved utilization of services. Monitors utilization indicators; identifies and escalates programs; and initiates and evaluates action plans for achieving the areas utilization goals/targets.Consistently supports compliance and the 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 the Hospitals policies and procedures. In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Hospitals Mission Statement, 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.

Utilization Management Position

Luke & Associates seeks a civilian clinical nurse to serve as utilization management for Langley Air Force Base Medical Center in Virginia. Qualified candidates will have at least one year of experience in utilization management; CPHM certification is not required but preferred. Any state license can be used. Position offers a generous salary and benefit package.

This position is responsible for enhancing patient care and satisfaction through quality activity, monitoring and to coordinate and execute the specific tasks required for efficient and effective operation of the quality improvement program in accordance with department, contractual and regulatory agency standards.Qualifications: Good organizational and interpersonal skills.Computer skills, basic keyboard knowledge. Willingness to be flexible with work scheduleKnowledge of managed care or utilization review or hospital quality. BSN or 2-4 equivalent years experience in managed care.1-2 years experience in utilization management/QI activity. 3-5 years of clinical experienceCurrent RN license issued by the state of IllinoisCurrent CPR certificationAdvocate Health Care, based in Oak Brook, Illinois, is the largest fully integrated health care delivery system in metropolitan Chicago and the state of Illinois, and is recognized as one of the top health care systems in the country. Advocate is the second largest private sector employer in metropolitan Chicago with more than 25,000 associates and has the largest trauma network in the state of Illinois.

Opportunity to implement a new innovative and creative care model

Position Focus This position will direct care management within three medical centers Be a part of a New Hospital of the Future program focusing on a collaborative care modelEstablish and roll out care management at admissions to quickly assess risk and ensure the allocation of appropriate resourcesOpportunity to work within a progressive organization focused on LEAN quality initiativesOrganization ThedaCare consists of four hospitals: Appleton Medical Center, Theda Clark Medical Center, New London Family Medical Center and Riverside Medical Center, as well as a primary care practice of more than 120 employed physicians at 21 sites throughout the service area Two of the hospitals were named Consumer Choice Hospitals for the eighth year in a row by the National Research Corporation and are leaders in cardiac, cancer and orthopedic care--the medical center pioneered local treatment of cardiovascular disease in northwestern Wisconsin and initiated the first family fertility program in the areaThedaCare was chosen as one of only six sites selected to pilot a new hospital discharge project titled - The Better Outcomes for Older Adults through Safe Transitions (BOOST) project The system was named 100 Most Wired by the American Hospital Association for the eighth year in a rowCommunity With a population over 75,000, Appleton, Wisconsin is located on the Fox River near Lake Winnebago and Lake MichiganThe city is beautiful and a pleasant place to live with numerous trees and parks, diverse quality restaurants and a safe communityThe community offers rich culture, high employment, a low cost of living and public and private schools as well as a few universities and vocational schoolsQualifications Bachelors degree Must possess an in-depth knowledge of care management and regulatory requirementsUnderstanding of hospital LEAN principles is ideal

Schedule: Temporary position from 01/01/2010-12/31/2010. On-Call position to include Monday - Friday within the hours of 8:30AM - 5:00PM.POSITION TITLE: Coordinator, MD Telephonic Patient CarePURPOSE: Responsible for initiating and consistently evaluating the medical necessity and appropriateness of members/patients level of care; maintaining efficiency and integrity of the referral process and to monitor the quality of outcomes for the patient and the health plan.This position consistently supports compliance and Kaiser Permanente’s Code of Conduct by adhering to federal, state and local laws and regulations, accreditation and licenser requirements and Kaiser Permanente’s policies and procedures.ACCOUNTABILITIES: 1. Maintains the data integrity and authorization process of the referral system2. Provides urgent/emergent care management, utilization and referral management for members/patients in the ED or other outpatient/preadmission settings.3. Interacts with physicians to influence actions and decision in cases where a physician needs assistance to expeditiously transition a member/patient to the appropriate level of care4. Initiates the denial letter process in accordance with Kaiser Permanente, state and federal regulations.5. Works with physician to coordinate repatriation of both In and Out of Area members transferring from one facility to another.6. Coordinates transport by ambulance for members transferring from one facility to another in accordance with Health Plan policies and procedure7. Provides case management services8. Provides utilization management services9. Provides quality screening10. Coordinates communication and promotes collaboration between the disciplines providing care or case management within the Kaiser Permanente system11. Performs other related duties as directedMINIMUM REQUIREMENTS Relevant Years of Experience:- Three years of clinical experience with two years of utilization management experience - Experience with computer software programs in a Windows environmentEducation and/or Classes:- BS preferredLicense, Certification and/or Designation:- RN license in jurisdiction where assigned Essential Functions (i.e. bending, lifting, and mobility): See Functional & Environmental Evaluation (FEE) Form. Kaiser Permanente’s Service Standards:-We are Kaiser Permanente - Dedicated Professionals.- We value and appreciate each other.- We make eye contact and display appropriate body language (E.G., Smile)- We keep our promise and commitment to excellence.- We promote wellness and living well.- We address our members’ concerns and their unique needs.- We provide immediate service recovery.- We treat each person with respect and dignity.- We speak and listen with empathy.- We thank each and every member for choosing Kaiser Permanente. The critical skills needed to perform this job are: - Ability to effectively communicate - Ability to conform to established policies and procedures - Ability to analytically problem solve and make decisions - Ability to tolerate and cope with ambiguity - Ability to work as a team member - Proficiency in the use of applicable computer software

Saint Vincent was recognized with a 2009-2010 Hospital Value Index “Best in Value Award”, a result of the study conducted by Data Advantage, LLC, the nation’s leader in measuring healthcare value. 1 of only 2 Massachusetts hospitals to receive the award.

Department: Nursing Administration - #8720 Schedule: Part Time Shift: Eves/Nights Hours: 24F/Schedule & Shift Varies (Eve/Nights) Job Details: Responsible for 24 hour planning, organizing, directing, coordinating, and evaluating activities related to Bed Control, including recommendations for nursing float pool assignments. Participates in the planning of patient care needs and coordinates patient activities with related departments. Establishes and maintains a systematic review and assessment of bed availability. Ensures appropriate assignment based on clinical need and staffing constraints. Works with other departments to assess the need for standards to optimize the utilization of beds (inclusive of pre-operative days and direct admissions). Current & Valid RN license required. B.A. or B.S. and RN required. At least 5 years experience in a health care setting. A minimum of two years of experience in an acute care facility required. Experience in Utilization Review activities and/or in an admission office setting preferred. Experience dealing with certifying organizations (JCAHO) preferred. Basic Life Support (BLS) required.

Department: Nursing Administration - #8720 Schedule: Part Time Shift: Eves/Nights Hours: 32F/Shift & Schedule Vary (Eve/Nights) Job Details: Responsible for 24 hour planning, organizing, directing, coordinating, and evaluating activities related to Bed Control, including recommendations for nursing float pool assignments. Participates in the planning of patient care needs and coordinates patient activities with related departments. Establishes and maintains a systematic review and assessment of bed availability. Ensures appropriate assignment based on clinical need and staffing constraints. Works with other departments to assess the need for standards to optimize the utilization of beds (inclusive of pre-operative days and direct admissions). Current & Valid RN license required. B.A. or B.S. and RN required. At least 5 years experience in a health care setting. A minimum of two years of experience in an acute care facility required. Experience in Utilization Review activities and/or in an admission office setting preferred. Experience dealing with certifying organizations (JCAHO) preferred. Basic Life Support (BLS) required.

Abrazo Health Care with five hospitals in Arizona, five imaging centers and 19 primary care offices is changing the face of healthcare in Maricopa County.

Under general supervision of the Regional Coding Manager/Manager of Inpatient Coding, the Clinical Documentation Specialist is responsible for improving overall quality and completeness of clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physician, case management, nursing staff, other patient caregivers and coding staff. Minimum Qualifications: Graduate of an approved Health Information Technology/Management program with credentials of RHIA, RHIA eligible, RHIT, RHIT eligible, CCS, CCS-P and/or graduate from an accredited nursing program with RN licensure. Two years of experience in acute care setting. One year of inpatient coder experience preferred. Minimum Requirements: RHIT, RHIA, or CCS if RN graduate from an accredited nursing program with RN licensure

PositionNewly created position to lead the redesign and restructure of the Case Management Department Will have overall responsibility for Utilization Review, Case Management and Social ServicesThis position will build strong relationships with outsourced Physician Advisors, Clinical Documentation and Clinical Outcomes, Hospitalists, Nursing, revenue cycle team and on-sight reviewersWorking knowledge of InterQual Criteria requiredCase management experience in hospital and insurance company preferredHospital Augusta Medical Center is a 255-bed, Joint Commission accredited community hospital serving the needs of a large part of Virginia´s beautiful Shenandoah ValleyWith over 225 active, full-time physicians, the facility is committed to standards of clinical excellence, satisfaction, and stewardshipServices offered include behavioral health, diagnostics, emergency care, women´s health, radiology, surgery, rehabilitation, as well as a pain management clinicThis casual and family-like hospital is listed as one of Solucient´s Top 100 HospitalsCommunity The community of 65,000 is nestled between the Blue Ridge, Shenandoah and Allegheny mountains of VirginiaSitting at the crossroads of the Shenandoah Valley, residents find themselves presented with majestic scenery, and historic and cultural attractions, as well as a wealth of recreational activities Hospitality abounds at quaint bed and breakfasts, local and national restaurants, and numerous antique, gift and craft shopsThe area features seasonal events such as the Virginia Fall Foliage Festival, the Daylily and Wine Festival, and the Victorian Spring Festival

At Citrus Valley Health Partners, our family of dedicated nurses and other health care professionals live out a mission to heal people in body, mind and spirit.

Delivering world-class health care to our community, one patient at a time...At Citrus Valley Health Partners, our family of dedicated nurses and other health care professionals live out a mission to heal people in body, mind and spirit. With services ranging from family-centered maternity care and high level neonatal care to technologically advanced cardiac services and an innovative palliative care program, our work touches people at every stage of their lives. Citrus Valley Health Partners is about caring for our community and caring about our employees by giving them the opportunity to make a difference every day.Share our vision. Live our mission. Learn about CVHP.Manager Care CoordinationAs a member of our team, you will provide direct supervision to the Care Coordination staff in the areas of Utilization Management and Discharge Planning, as well as manage denial of services notifications, departmental Performance Improvement Program, denial statistics and appeals. You will promote organizational interdisciplinary collaboration. Qualified candidate must have a current CA RN license, BLS certification, an Associates or diploma degree in Nursing (Bachelors degree in Nursing or in a related field is preferred), and 2 years recent acute clinical experience. Experience with discharge planning, utilization management and criteria sets is preferred. Requires effective written, verbal and time management skills, knowledge of medical information systems, ability to work independently as well as establish relationships and function within a team, and ability to use a computer and make notations. Excellent customer service skills is a must.We offer competitive compensation and benefits in a positive work environment.

Position Summary:Demonstrates successful appeal and audit responses to third-party payers concerning hospital clinical and bill claim denials. Serves as an educational resource for staff and physicians to reduce or eliminate denials. Position Qualifications:Massachusetts licensure as registered nurse required. Knowledge of CPT and ICD-9-CM required. Thorough knowledge of HIPPA, Medicare and Medicaid compliance regulations.Third party payer and billing system knowledge preferred. Ability to effectively use specialized computer based systems for gathering, reporting, and analysis of clinical data. Excellent organizational and communications skills required.Preferred: Knowledge of CMS billing and compliance regulations in the acute care setting, third party payer process, and Utilization Management experience.Required: RN licensure, knowledge of CPT and ICD-9 coding, excellent communication and organizational skills.

North Star Hospital

North Star is Alaska’s premier behavioral health provider that specialized in helping young people with life’s challenges. We recognize that childhood should be a time of joy, fulfillment, growth, and nurturing care. We also recognize that situations happen that are beyond young people’s control or ability to effectively handle. Our programs at North Star work with the family and the community to help facilitate optimal growth and nurturing throughout times of childhood adversity. Our goal is to help young people get on a track that leads to a life of youthfulness – the life that child and adolescents deserve. We are currently searching for Utilization Review Coordinator to join our established team. The UR Coordinator will be responsible for ensuring that financial benefits are maximized in the treatment and discharge planning for assigned cases through initial and continued stay reviews and obtaining prior authorization work for discharge services. They will also serve as an effective liaison between the business offices and treatment team, implementing the discharge plan and active pursuit of appeals. This position requires a Master’s degree in Psychology, Counseling, Social Work, or other related field. Prior experience in UR is preferred. This candidate should have a strong knowledge of psychiatric care service delivery systems and third party reimbursement, as well as an understanding of admission and discharge function. Familiarity with psychiatric terminology, diagnostic terms and treatment modalities is preferred as well as a knowledge of medical record keeping and consults. Strong verbal and written communication skills and the ability to effectively meet deadlines are a must.

Position Purpose:- Perform duties to direct and coordinate the medical management, quality improvement and credentialing functions for the assigned health plan based on, and in support of the companys strategic plan; establishing the strategic vision and attendant policies and procedures.Knowledge/Experience: - Equivalent to a four (4) year education in nursing. - Advanced education in nursing, health care, business or public administration preferred. - Thorough knowledge of a specialized or technical field such as clinical nursing, managed care, and healthcare administration. - Thorough skills knowledge of quality improvement practices. - Familiarity of medical information systems, medical claims payment process, medical terminology and coding.- Familiarity of case management practices, managed care, and Medicaid programs. - Familiarity of National Committee on Quality Assurance (NCQA) accreditation process and standardsCompetencies Executive: Integrity, Flexibility, Communication, Critical Thinking, Strategic Thinking, Leadership, Ability to Execute, Business Acumen, CoachingPosition Responsibilities:- Direct and coordinate activities of department and aid the chief officer of the health plan and appropriate corporate staff in formulating and administering organizational and departmental policies. - Review analyses of activities, costs, operations and forecast data to determine department progress toward stated goals and objectives. - Serve as a member of management committees on special studies. - Administer and ensure compliance with National Committee on Quality Assurance (NCQA) and/or Joint Commission on Accreditation of Healthcare Organization (JACHO) standards as determined for accreditation of the health plan. - Participate in, attend and plan/coordinate staff, departmental, committee, sub-committee, community, State and other activities, meetings and seminars. - Participate in provider education and contracting, as necessary.

Our medical group has over 400 practitioners who deliver medical care to 265,000 Kaiser Foundation Health Plan members throughout the Atlanta area in our 15 medical centers.

Primary Duties and Responsibilities:Responsible for carrying out utilization review, quality review and discharge planning on inpatient admissions including rehabilitation units at core facilities according to policy. The activities will include onsite admission and concurrent review for inpatient admissions, discharge planning, identification of patients for case management, communication with case managers, home care reviewers, Social Workers, members and providers, quality improvement reviews, and education of the member/family, provider and hospital staff. Achieves desired utilization and quality outcomes and promotes high customer satisfaction to the population served.Minimum Education and Experience Requirements:•Unrestricted current Registered Nurse (RN) licensure/ Licensed Clinical Social Worker (LCSW) in the state of Georgia required or documentation to show intent to seek license•Functional knowledge of computers •Experience with managed health care delivery including Medicare•Working knowledge of all relevant federal, state, local and regulatory requirements•At least two (2) years of experience in utilization or case management, discharge planning and quality improvement in a health care or managed care settingPreferred Education and Experience:•B.S. in Nursing preferred •Three (3) years of clinical nursing preferably in a complex area such as critical care.

Under the supervision of the Director, the Clinical Documentation Specialist will be responsible for improving the overall quality and completeness of clinical documentation. Specialist collaborates extensively with physicians, nursing staff, other patient caregivers, and Health Information Management coding staff to support that appropriate reimbursement and clinical severity is captured for the level of service rendered to all patients with a DRG based payer. Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes. Educates all members of the patient care team on an ongoing basis. This position is full-time, 40 hours benefit eligible and the location at Vista Medical Center East, in Waukegan, ILQualifications Education:• Bachelor of Science in NursingLicenses / Certifications (any of the below will qualify):• RHIT• RHIA• CCS• LPN or RN with case management or coding experience in an acute care settingExperience:• 2 years experience in nursing, or other clinical area • 2 years of utilization review/case management in an acute care facility.• Coding Skills with experience in ICD-9-CM and working knowledge of the AHA Coding Clinic• Possess in-depth knowledge of medical and anatomical terminology, reimbursement principles, health record content, sequencing of diagnoses, and the use of coding software.• Effective interpersonal skills in order to interact effectively with all levels of hospital personnel. • Organization and prioritization skills. • Effective written and verbal communication skills. • Analytical skills.• Proficient computer skills.