Clinical Operations Specialist

2 weeks ago

Atlanta, Georgia, United States Pacer Staffing Full time

Shift: Standard Shift

Note:

  • Availability to work any shift.
  • Regular and reliable attendance is essential.
  • Operates within a standard office environment, with minimal travel required.
  • Extensive computer work involving prolonged periods of sitting.

Job Overview:

Summary:

  • This individual contributor role reports to the Directors of Utilization Management (UM) and Referral Management (RM), supporting both RM and UM program processes. Responsibilities include developing training materials, desk procedures, conducting research on standards of practice, and performing process audits.
  • The position involves training staff on RM and UM processes while assisting in monitoring adherence to UM accreditation standards. It also includes coordinating the development and revision of Policy Keys, managing ongoing research and coding for the Referral and Authorization Decision Support (RADS) tool, and playing a significant role in the ongoing development of key processes and techniques for measuring outcomes.

Key Responsibilities:

  • Conduct research on TRICARE policy, operations, reimbursement manuals, and relevant clinical criteria resources to support the development of Policy Keys, clinical guidelines, and coding for the RADS tool.
  • Participate in Contract Modification meetings and processes as a Subject Matter Expert in UM and/or RM.
  • Train staff to utilize established criteria for evaluating medical necessity and appropriateness of care, including InterQual, Policy Keys, and the RADS tool.
  • Instruct staff in techniques for validating medical determinations through research, regulatory manuals, computer files, and medical documentation.
  • Assist staff with complex, in-depth analysis and review of UM processes.
  • Develop and maintain UM and RM desk procedures to ensure compliance with TRICARE Operational Manuals and best practices.
  • Train staff to resolve RM process issues, including data, eligibility, optimization, or provider search challenges using appropriate resources.
  • Collaborate with training and clinical leaders to develop, maintain, and assess RM and UM resource tools to enhance accuracy and efficiency.
  • Work with Clinical Operations Managers and Directors to create and implement audit tools for evaluating staff compliance with desk procedures and accreditation standards.
  • Assist in developing UM and RM productivity and performance measures.
  • Conduct periodic focused studies and performance audits.
  • Support department preparation for URAC accreditation surveys.
  • Serve as a Subject Matter Expert on UM and RM.
  • Engage in special projects and cross-functional teams.
  • Perform additional duties as assigned.
  • Regular and reliable attendance is required.

Required Qualifications:

  • Registered Nurse with a current unrestricted license in the appropriate state.
  • A minimum of 4 years of experience in Utilization Management.
  • Proficient in conducting in-depth analysis of clinical policy and medical records for appropriateness of care and/or level of care criteria.

Preferred Qualifications:

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

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