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Job Description:
The RN Clinical Data and Audit Nurse is responsible for the clinical content component of all data collection, audit activities, and utilization review to ensure high quality for all delegated contracted health plans. Provides utilization review and completion of authorization requests for contracted delegated health plans. The authorization requests include prior authorization, retro authorizations, inpatient authorizations, and skilled nursing authorizations, along with providing concurrent review and care coordination with discharge planning when needed. Collaborates with the Medical Director, management, clinical staff, and Health Plan staff to manage health plan-specific data, reports, and audits into a centralized data file, ensuring accuracy and accessibility to appropriate staff, along with utilization review. Provides data analysis regarding patient level and aggregate utilization and trend reports for each plan. Assists with evaluating plan utilization and with proactive patient engagement activities across the health continuum which includes case management, palliative care, mental health, wellness, and prevention.Education
Graduate of an Accredited School of Nursing - Required
Bachelor's Degree - Nursing - Required
Experience
1 year of performing health plan audits – Required
1 year of Utilization Management and Review – Required
1 year of Ambulatory Case Management and Population Health – Required
Certifications/Licensures
RN – Registered Nursing – California Board of Nursing – Required
Knowledge, Skills, and Abilities
Strong analytical skills, and ability to manipulate and interpret data.
Strong recall skills of clinical knowledge and critical thinking ability.
High degree of organizational skills, ability to set priorities, manage multiple demands, and the ability to
complete tasks under strict timelines.
Working knowledge of NCQA, DMHC, and CMS standards and requirements.
In-depth knowledge of InterQual evidence-based clinical decision support system.
Knowledge and skills with EPIC (EMR), PC, word processing, Excel, and database programs.
Work Rules and Practices
Develops and maintains professional working relationships among department colleagues, providers,
collaborating partners, and the JMH system employees.
Demonstrates organizational skills, ability to set priorities, and manage multiple demands.
Demonstrates effective oral and written communication, interpersonal, problem-solving, conflict
resolution, presentation, time management, and positive communication skills.
Maintains strict confidentiality and demonstrates a clear understanding of HIPAA Privacy and California Confidentiality of Medical Information Act provisions surrounding patient-specific processes; maintains compliance with John Muir Health policies.
Provides a safe working environment for the department by having knowledge of relevant policies and procedures. Report and correct unsafe conditions.
Supports the mission, philosophy, and goals of John Muir Health.
Work Shift:
08.0 - 08:30 - 17:00 No Waive (United States of America)Pay Range:
$79.81 - $107.76HourlyNote: Positions at JMH which are exempt (not eligible for overtime) under the level of Manager are listed as hourly for compensation purposes on this posting. The work shift will contain the word ‘exempt’ on it.
Scheduled Weekly Hours:
40Learn more about this Employer on their Career Site
