Clinical Ops and Policy Clinical

Job Title: Clinical Ops and Policy Clinical

Location: Re mote

Duration: 3 months + Contract to hire

Shift: Standard shift

Job description

Job 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.

Education & Experience

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 criteriarequired

Preferred:

· TRICARE experience

· Qualified for Certified Professional Utilization Review Certification or Certified Professional Utilization ManagementCertification

· Experience in UM policy writing, development, training, and/or auditing

· Experience with clinical coding research

· Experience with managed care programs and processes

Key Responsibilities

· Researches TRICARE policy, operations, reimbursement manuals and appropriate clinical criteria resources to supportdevelopment 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, andmedical 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 bestpractices.

· Trains staff to determine RM process resolution to include data, eligibility, optimization or provider search issues usingappropriate resources.

· Works with training, and clinical leaders to develop, maintain and assess RM and UM resource tools to support accuracyand efficiency.

· Works with Clinical Operations Managers and Directors to develop and implement audit tools for evaluating staffcompliance 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.

Benefits-

Medical, Dental and Vision Coverage

Generous paid me off

401(k) Re rement Savings Plan (with matching)

Short-term and long-term disability, basic life, and accidental death and dismemberment insurance

Tui on reimbursement Paid volunteer me