Per Diem Clinical UR Specialist

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 Not Benefits Eligible Work Shift Day - 8 Hour or less Shift (United States of America) Department 6441 Administration-KHRH

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.

• 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.
• Experience
  
  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

• 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. Refers to Case Management team any variances that relate to concurrent review of the medical record. During chart review, is aware of criteria for quality variances. Complies with Kaweah Health Policy by reporting utilization variances to Case Management Committee and/or the P.I. department as indicated.
• Reviews medical records for admission and continued stay utilizing Inter Qual Severity of Illness and Intensity of Service for appropriateness of the admission, continued stay, and utilization of resources. Must also review all cases transferred in and out of special/intensive care areas using specific criteria.
• Participants in Sub Committee reviews as designated.
• 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…