Summary:

Responsible for assuring the receipt of high-quality, cost-efficient medical outcomes for those enrollees identified as having the need for inpatient/outpatient precertification.

Essential Duties & Responsibilities:

• Review precertification requests for medical necessity, referring to the Medical Director those that require additional expertise.
• Review clinical information for concurrent reviews.
• As part of the UMRN program, conduct ongoing availability, monitoring and oversight of non-clinical staff activities.
• Establish effective rapport with other employees, professional support service staff, customers, clients, patients, families, and physicians.
• Employ effective use of knowledge, critical thinking, and skills to:
• Advocate quality care and enhanced quality of life.
• Prevent patient complications during hospital stay.
• Advocate decreased hospital stay when appropriate.
• Maintain accurate records of all patient related interactions.
• Maintain regular and punctual attendance.
• Other duties as assigned.

Supervisory Responsibilities:

None.

Desired Skills & Qualifications:

• Working knowledge of computer applications/software to include Microsoft Office programs, MS Outlook (e-mail), and internet familiarity is required. The ability to input, extract, and format data from established databases is desired.
• Ability to effectively read, write and speak English in order to communicate with all patients and other healthcare providers.
• Ability to effectively communicate and collaborate with a diverse group of people for the purpose of informing the healthcare team of plans/actions, for teaching/education to benefit the patient/family and organization.
• Effectively uses appropriate communication format in addressing professional issues.
• Excellent written communication skills to perform accurate documentation, both written and electronic, of all activity in accordance with requirements.
• Must demonstrate ability to apply critical thinking skills and expertise in resolving complicated healthcare, social, interpersonal and financial patient situations.

Work Schedule:

Full-time. May be required to work additional hours as needed to complete assignment or project.

Physical Demands:

Position consists of sitting for long periods of time, using hands/fingers, handling, reaching with hands and arms, speaking or translating. Periods of walking, standing, bending, kneeling, stooping, crouching, and lifting boxes weighing up to 30 pounds. Moderate to extended periods of office work with heavy periods of computer usage. May be assigned occasional to moderate periods of analytical tasks requiring extensive reasoning abilities. It is Katmai's business philosophy and practice to provide reasonable accommodations, according to applicable state and federal laws, to all qualified individuals with physical or mental disabilities.

Work Environment:

Work is performed primarily indoors at a well-lit military treatment facility such as a clinic, outpatient facility or hospital. The environment is normally air conditioned, but conditions may change dependent upon circumstances. Work may need to be performed in a fast-paced environment requiring quick thinking and rapid judgements. Employee will be exposed to a wide variety of clients in differing functions, personalities and abilities. Exposure to bloodborne pathogens and bodily fluids, latex, radiation or other contaminants and safety issues. May be exposed to infection or diseases from contact with patients. Work is highly social with patients and can be stressful with a high emotional element. Decisions made may substantially impact patients and their families.

Minimum Qualifications:

• Bachelor of Science in Nursing (BSN) is required.
• Minimum of 2 years of prior experience in Utilization Management.
• Must possess a current, active, full and unrestricted Registered Nurses (RN) licensed in Colorado, be able to practice using a nurse compact state license or have a license from any United States jurisdiction (with no limitations, stipulations or pending adverse actions).
• Certification by a Utilization Management-specific program such as Certified Professional in Healthcare Management (CPHM) is desired.
• Knowledge of medical privacy and confidentiality (Health Insurance Portability and Accountability Act [HIPAA]), and accreditation standards of Accreditation Association for Ambulatory Health Care (AAAHC), The Joint Commission (TJC), and Clinical Practice Guidelines (CPGs).
• Must have knowledge and experience, or demonstrate comprehension during training, with software and databases currently employed at the MTF (e.g. Microsoft Office, Access, Excel and PowerPoint; Composite Health Care System [CHCS], Armed Forces Health Longitudinal Technological Application [AHLTA]).
• Must have a working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Current Version (ICD), and Current Procedural Terminology-Current Version (CPT) coding; and McKesson (InterQual) and/or Milliman Care Guidelines.
• Must have and maintain current certification in Basic Life Support (BLS) from the American Red Cross. This certificate must be current at all times.
• Must obtain and maintain the site's required health screening and immunization requirements.
• Must obtain and maintain any necessary security access and/or background checks.
• Must obtain and maintain all required documents, certifications, licenses, etc. listed on the credentialing checklist, sent by Katmai's Credentialing Specialist, for this position for initial hire.

COMPENSATION & BENEFITS PACKAGE

• Pay is: $32.00 to $38.41per hour.
• Eligible Benefits: Medical, Dental, Vision, Group Term Life & AD&D Insurance, Voluntary Life and AD&D Insurances, Voluntary Long-Term & Short-Term Disability Insurance, Dependent Spouse Life Insurance and Dependent Life Insurance, Prescription Drug Coverage, Hearing Coverage, 401(k) Savings Plan, Employee Assistance Program (EAP), Vacation & Paid Personal Time, 11 Paid Federal Holidays, and Leave of Absence.

Compliance:

To be considered for this position, all applicants must apply on the company website,

We are a VEVRAA Federal Contractor

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity or national origin, disability status, protected veteran status, or any other characteristic protected by law.

Preference will be given to Ouzinkie Shareholders, Descendants of Shareholders and Spouses of Shareholders in accordance with Title 43 U.S. Code 1626(g) and Title 42 U.S. Code 2000e - 2(i).

Executive Order 11246, as amended, protects applicants and employees from discrimination based on inquiring about, disclosing, or discussing their compensation or the compensation of other applicants or employees.