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Clinical Ops

2 months ago

Atlanta, United States Pacer Staffing Full time

Shift: Standard Shift

Note:

  • Availability to work any shift.
  • Regular and reliable attendance
  • Works within a standard office environment, with minimal travel
  • Extensive computer work with prolonged sitting

Job Description:

Summary:

  • This individual contributor position reports to the Directors of Utilization Management (UM) and Referral Management (RM) and supports both RM and UM program processes. Develops training materials, desk procedures, conducts standards of practice research and focused studies; and conducts process audit.
  • Trains staff on RM and UM processes and assists with monitoring adherence to UM accreditation standards. Coordinates Policy Key development and revision; manages ongoing research and coding for the Referral and Authorization Decision Support (RADS) tool; and plays a significant role with ongoing development of key processes and techniques for measuring outcomes.

Key Responsibilities:

  • Research TRICARE policy, operations, reimbursement manuals and appropriate clinical criteria resources to support
  • development of Policy Keys, clinical guidelines and coding for the RADS tool.
  • Participates with Contract Modification meetings and processes as a UM and/or RM Subject Matter Expert
  • Trains staff to use established criteria for evaluating medical necessity and appropriateness of care, including InterQual, Policy Keys, and consulting the RADS tool.
  • Trains staff in techniques for validating medical determinations through research, regulatory manuals, computer files, and medical documentation.
  • Assists staff with complex, in-depth analysis and review of UM processes.
  • Develops and maintains UM and RM desk procedures ensuring compliance with TRICARE Operational Manuals and best practices.
  • Trains staff to determine RM process resolution to include data, eligibility, optimization, or provider search issues using appropriate resources.
  • Works with training, and clinical leaders to develop, maintain and assess RM and UM resource tools to support accuracy and efficiency.
  • Works with Clinical Operations Managers and Directors to develop and implement audit tools for evaluating staff compliance desk procedures and accreditation standards.
  • Assists with developing UM and RM productivity and performance measures.
  • Completes periodic focused studies and performance audits.
  • Assists in department preparation for the URAC accreditation survey.
  • Functions as Subject Matter Expert on UM and RM.
  • Participates in special projects and cross-functional teams.
  • Performs other duties as assigned.
  • Regular and reliable attendance is required.

Required:

  • Registered Nurse, with current unrestricted license in appropriate state
  • 4+ years Utilization Management experience
  • Proficient at in-depth analysis of clinical policy and medical records for appropriateness of care and/or level of care criteria required.

Preferred:

  • TRICARE experience
  • Qualified for Certified Professional Utilization Review Certification or Certified Professional Utilization Management
  • Certification
  • Experience in UM policy writing, development, training, and/or auditing
  • Experience with clinical coding research
  • Experience with managed care programs and processes