Case Review Registered Nurse

Tuba City Regional Healthcare Tuba City, AZ 86045, US

POSITION SUMMARY

This position facilitates the analysis of medical staff quality and performance data for the organization through coordination of information including data collection, analysis and trending of required medical staff quality and peer review activities, and other select clinical outcome measurements. This position serves as assisting the medical staff with practitioner specific quality monitoring and reporting. This position manages issues that are brought up regarding the quality of practice by providers, evaluates and investigates quality issues. Responsible for managing Ongoing Professional Practice Evaluations/Focused Professional Practice Evaluations. Supporting the Peer Review Committee and other Quality related projects. This Registered Nurses will be evaluating the quality and appropriateness of care provided by their peers, aiming to improve patient safety and practice standards through a non-punitive, continuous learning process. The role of the Case Review RN is to establish, promote and monitor seamless care for TCRHCC patients.

Qualifications

NECESSARY QUALIFICATIONS

Education:

Bachelor’s degree in nursing and Master’s Degree in Business Administration or other Master’s degree in healthcare.

License:

A valid, current, full and unrestricted Professional Nursing License to practice nursing in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States

Experience:

Five (5) years of supervisory experience in discharge planning, case management, or utilization review in an acute-care health care setting or related healthcare clinical leadership

Other Skills and Abilities:

A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers. All employment references must address and indicate success in each one of the following areas:

Accessing community resources for patient referrals
Elimination of potential conflicts of interest including professional, organizational, and/or personal bias inherent to review programs performed or supported with internal review.
Providing a systematic and scalable approach ensuring review criteria and results are accurate, reliable which reduces risk by identifying trends and potential issues of clinical staff performance, deficiencies, and errors.
Knowledge of diagnosis related groups (DRG) and documentation requirements
Positive working relationships with others
Possession of high ethical standards and no history of complaints
Reliable and dependable; reports to work as scheduled without excessive absences
Ability to sense varying skill levels and direct instruction accordingly
Detail oriented, well organized, and applies critical thinking, reasoning, deduction, and inference skills
Knowledge of report writing, graphical analysis, and working with computer spreadsheets and database programs
Completion of and above-satisfactory scores on all job interviews, demonstrating to the satisfaction of the interviewees and TCRHCC that the applicant can perform the essential functions of the job
Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job
Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job
Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading or incomplete information, as determined by TCRHCC

MENTAL AND PHYSICAL EFFORT

The physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform essential functions.

Physical:

The work involves prolonged periods of sitting in an office setting operating a personal computer, walking throughout the hospital to obtain and review medical records, and standing while inquiring with providers and clinical staff. The Incumbent may occasionally need to drive, bend, climb, kneel, crouch, twist, maintain balance, and reach. There may be times of distant travel for ongoing and advanced training. Occasional travel to the satellite health centers for on-site reviews. The Incumbent will frequently need to be able to lift, pull, and push up to 10 pounds. This position requires the sensory ability for frequent use of far vision, near vision, color vision, depth perception, seeing fine details, hearing normal speech, telephone use, and hearing overhead pages over a loudspeaker. The incumbent must be able to utilize hand manipulation to do simple grasping and use of keyboard for prolonged time during work day. The position requires frequent firm grasping and fine manipulation.

Mental:

The work requires the ability to deal relatively independently with the interrelated elements that affect data analyzing and reporting, to resolve complications and controversial matters. This position requires the mental & emotional requirement ability to cope with high levels of stress; make decisions under high pressure; copy with anger/fear/hostility of others in a calm way; manage altercations; concentrate; handle a high degree of flexibility; handle multiple priorities in a stressful situation; work alone; demonstrate a high degree of patience; and work in areas that are close and crowded. May occasionally be required to adapt to shift work.

Environmental:

The incumbent may be exposed to the following environmental situations: Infectious Diseases, chemical agents, dust, fumes, gases, extremes in temperature or humidity, hazardous or moving equipment, unprotected heights, and loud noises.

Responsibilities

ESSENTIAL FUNCTIONS:

Reviews patient records and clinical documentation to assess the appropriateness and necessity of healthcare services, ensuring quality and cost-effectiveness of care
Resolves informal/formal complaints and grievances within jurisdiction and refers appropriately to a higher level of management if needed. As appropriate, refers instances of inappropriate patient care, discharge delays, and so on to the Risk Manager and /or Clinical Division.
Review patient records, thoroughly examine patient charts, clinical documentation, and billing information to assess the appropriateness and necessity of services provided.
Perform chart reviews to identify quality, timeliness, and appropriateness of patient care.
Refer cases as appropriate to physician advisors for review and determination.
Requires experience in performance improvement methodologies; quality measurement; and data analysis using statistical principles.
Prior experience in hospital or clinical management preferred.
Requires computer knowledge.
Windows application: Skilled in the use of select Microsoft Office Applications, e.g. Word; Excel and PowerPoint or other database management applications.
Requires strong written and verbal communication skills and the ability to work effectively with all levels of the organization and with members of the medical staff.
Requires strong public speaking skills and the ability to deliver effective presentations and education to large groups of physicians and staff.
Requires ability to prioritize multiple projects and the flexibility to accommodate changing priorities.
Effectively communicates and coordinates processes to assure the continuity of patient care to outside providers and promote patient advocacy among Navajo Area Indian Health Services/Service Units, and Federal and State entities.
Develops and implements policies and procedures regarding case management eligibility, alternate resource programs, referral/notification process, interdepartmental relationship and responsibilities; promote patient access to the appropriate level of care, prevent over or under utilization of resources, maximize the use of alternate resources, and supports continuity of care.
Assists with review, research, and decision of first level appeal process with Purchase Referred Care
Provides clinical expertise, skills, and behaviors appropriate to the population(s), served, and based on specific criteria and/or age-specific considerations. Supports, educates, and oversees the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation enhancement guidelines for selected patient populations.
Collaborates with the Physician Advisor or designee in leading and facilitating the Utilization Review Committee, develops and interprets reports (i.e. statistical, financial, trends), provides data for the PI Committee and submits reports, as required, on outcomes, clinical quality documentation and insurance medical necessity criteria.
Complete task training for all routine cleaning and decontamination processes for all surfaces contaminated by a communicable disease to ensure a high level of patient, visitor, employee, and external customer
Performs other assigned duties as needed

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This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law. Job Level: Non-Management Non-Exempt Workshift: Job Family: MED > Licensed Nurse Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration .