Job Purpose: The Clinical Nurse Coordinator is a state licensed Registered Nurse that provides management oversight in implementing the Utilization Management (UM) department functions, including prior authorization decisions and retrospective reviews for nonpatient laboratory services.
Roles and Responsibilities:
- Provide leadership in the design and implementation of UM policies, processes, and procedures
- Ensure quality of UM services and that contractual and regulatory requirements remain compliant through daily supervision of assigned utilization management team and required reporting.
- Maintain knowledge of regulatory and accreditation agencies and related delegated requirements pertinent to case management, such as BCN Medical Policy and NCQA
- Oversee the review of quality concerns identified through the QI process and the implementation and monitoring of corrective action plans
- Conducts clinical reviews of authorized approval and denial recommendations from JVHL Prior Authorization Specialist for prior and retro authorizations
- Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care for member
- Collects, documents, and maintains all member clinical information accurately in health management systems to ensure compliance with regulatory guidelines
- Provides training to Utilization Management team to promote high quality care to members & clients
- Resolves or facilitates resolution of the highest risk and/or complex prior authorization issues
- Identify opportunities to create efficiencies in the UM program and activities, collaborate to design and implement improvements
- Participate in Internal UM Committee
- Comply with all JVHL policies and standards
Other Roles and Responsibilities:
- Develop/maintain memberships in professional organizations
- Maintain valid licensure
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- Contribute to other areas and perform duties at JVHL as needed
- Ability to work independently and collaboratively in a fast-paced environment
- Update job knowledge by participating in education opportunities
- This position will require access to Patient Health Information (PHI), both electronic and hardcopy, so employee will be required to assist in its protection by following corporate policies and procedures that are designed to maintain the privacy and security of PHI.
Education/Qualifications:
Graduate from an Accredited School of Nursing or bachelor’s degree in nursing and 2 – 4 years of related experience.
Experience in case review, utilization management and prior authorization requests
Preferred Skills:
Familiarity with clinical decision-making criteria and evidence-based guidelines used in the prior authorization process
Knowledge of Medicare and Medicaid regulations
Knowledge of NCQA Utilization Management processes
