Utilization Review Nurse

Job Summary Coordinates and supervises data management, analyses and reporting for KFH utilization management and Continuing Care Services, SCPMG, KFHP Outside Services management (i.e., day utilization at Outside facilities, and the Emergency Prospective Review Program and Air & Ground Transportation Program, using (implementing and refining) computerized data management systems and in manually maintained utilization data. Essential Responsibilities Coordinates and supervises data and reporting needs, data collection process and data processing issues and provides timely utilization data and analytic support. Frequent contacts with other organizational units and outside facilities staff to obtain, verify and/or provide information, e.g., works with Regional Claims and outside hospitals to reconcile billing charges. Answers inquiries and educate patients, physicians and hospitals on covered benefits and charges. Provides information and assistance to Health Plan members during claims review process and coordinates authorized and non-authorized claims review. Documents outside medical services and reinforce procedures for patients seen in outside emergency department. May coordinate and supervise Air & Ground Transportation and Prospective Review Authorization Program. Coordinates and supervises claims and referral information. Provides information regarding member admissions to outside facilities. Maintain the consistency and integrity of the non-KFH utilization bed track computerized data management system. May assist in scheduling patient appointments and coordinating patient care. Basic Qualifications Experience N/A Education High School Diploma or General Education Development (GED) required. License, Certification, Registration N/A Additional Requirements Experience applying analytic techniques and computer skills to hospital data. Strong analytic and verbal skills. Expertise with tracking, spreadsheets and graphic computer systems operating on PC mainframes. Knowledge of health plan benefits. Understanding of medical center operations, complex health systems, with the ability to quickly grasp regional policies, contract interpretation of out-of-plan medical services. Must be able to work in a Labor/Management Partnership environment. Preferred Qualifications Health Connect experience a plus. Associate of Arts or Bachelors degree preferred. KPHC - Medical records, Foundations / Mainframe experience. Notes If twelve (12) hour option chosen, shift will be 7:00 PM-7:30 AM, back up 8 hour shift will be 07:00PM -03:30 AM This is a temporary position for approximately three (3) months. This is a part time position, days and hours may vary. #J-18808-Ljbffr