Utilization Review Coordinator

  • Contra Costa County, CA
  • Concord, California
  • Mar 07, 2019
Full Time Public Health
  • Salary: $119,189.41 - $144,875.41 Annually

Job Description

The Position

Bargaining Unit: Local 21 - Non-Supervisory Nurse

CLOSING DATE: Open Until Filled



The Contra Costa County Health Services Department is recruiting for two (2) qualified individuals interested in theUtilization Review Coordinator position assigned to the Behavioral Health Unit (Mental Health and Substance Abuse Disorder) located in Concord, CA.

The Utilization Review Coordinator researches, studies, monitors and reports quality care issues and outcomes, communicates standards of care, initiates and coordinates related activities to improve care, performs data analysis, represents the department/division at internal and external meetings and preserves patient and staff confidentiality to ensure strict adherence to related activities privacy policies and regulations. Other responsibilities include participating in improvement teams and helps manage safety and improvement projects, participates and/or leads improvement teams, understands healthcare improvement methodologies, understands change process and theory, and performs retrospective and concurrent chart reviews for quality data abstraction and improvement purposes.

The Utilization Review Coordinator will need to keep abreast of health and government payer benefits, regulations and requirements, disease processes and treatment modalities, community standards of patient care, appropriate quality monitoring techniques, professional medical standards of practice, and accrediting organizations' requirements.

The ideal candidate will have a proven track record demonstrating the following:

  • Knowledgeable & experienced in Quality Measurement or Quality Improvement activities in an acute care hospital

Characteristics of the ideal candidate:
  • Knowledge of State and Federal Compliance Regulations
  • Clinical assessment and critical thinking
  • Effective oral and written communication skills
  • Interpersonal skills and time management skills


Read the complete job description at https://www.cccounty.us/hr. The eligible list established from this recruitment may remain in effect for six (6)months.

TENTATIVE EXAM DATES
Tentative Training & Experience Exam:Periodically Until Filled

Typical Tasks
MANAGEMENT RESPONSIBILITIES:
When assigned to the Contra Costa Regional Medical Center
Typical Utilization Review Discharge Planning Tasks:
  • Coordinates a team approach to review discharge planning
  • Performs care needs assessments that cover the continuum of care early in the treatment course to facilitate coordination of activities for a smooth and safe transition from one level of care to another and care coordination activities to assist the patient in navigating through the Health Care Delivery System
  • Monitors for adequate, consistent and appropriate medical record documentation as it relates to medical necessity, utilization or resources, quality of care and discharge planning and teaches providers appropriate and required medical documentation
  • Performs concurrent and retrospective inpatient or outpatient care review
  • Communicates with physicians and other healthcare professionals in relation to Utilization Review, Quality Assurance and Improvement and Case Management issues (includes gathering information, passing on information, coordinating and arranging for care, teaching providers)
  • Communicates with insurance agencies
  • Performs discharge planning duties including but not limited to obtaining authorization for medical equipment as needed upon discharge
  • May coordinate the transfer of a patient from CCRMC to other medical facilities
  • Attends the Utilization Management Committee and provides utilization statistics, trends and reports; informs committee members about related issues and problems; initiates action to improve utilization
  • Quality assurance/improvement tasks include researching, studying, monitoring and reporting quality care issues and outcomes, communicating standards of care, initiating and coordinating related activities to improve care
  • Participates in internal and external audits for reimbursement, quality of care and utilization of resources
  • Represents the department/division at internal and external meetings
  • Preserves patient and staff confidentiality to ensure strict adherence to related privacy policies and regulations
  • Keeps abreast of health payer benefits, regulations and requirements, disease processes and treatment modalities, community standards of patient care, appropriate quality monitoring techniques, professional medical standards of practice, government, payers, and accrediting organizations' requirements
  • Acts as a preceptor and orients new staff
  • Performs other related duties as assigned


Typical Performance Improvement Tasks:
  • Researches, studies, monitors and reports quality care issues and outcomes, communicates standards of care, initiates and coordinates related activities to improve care, performs data analysis
  • Preserves patient and staff confidentiality to ensure strict adherence to related privacy policies and regulations
  • Keeps abreast of State and Federal regulations and requirements, disease processes and treatment modalities, community standards of patient care, appropriate quality monitoring techniques, professional medical standards of practice, government, payers, and accrediting organizations' requirements
  • Participates in improvement teams and helps manage safety and improvement projects; Participates and/or leads improvement teams
  • Understands healthcare improvement methodologies
  • Understands change process and theory
  • Proficient in Word processing and data management software programs
  • Performs retrospective and concurrent chart reviews for quality data abstraction and improvement purposes
  • Acts as a preceptor and orients new staff
  • Coordinates Medical Staff Peer Review
  • Provides and promotes excellence in customer service for both internal and external customers.
  • Performs other related duties as assigned


When assigned to the Contra Costa Health Plan:
  • Coordinates a team approach to utilization review and case management activities
  • Performs prospective, concurrent and retrospective inpatient or outpatient care review
  • Quality assurance/improvement tasks include researching, studying, monitoring and reporting quality care issues and outcomes, communicating standards of care, initiating and coordinating related activities to improve care
  • Case management tasks include performing care needs assessments that cover the continuum of care early in the treatment course to facilitate coordination of activities for a smooth and safe transition from one level of care to another and care coordination activities to assist the patient in navigating through the Health Care Delivery System
  • Reviews requests for services, which require prior authorization to determine if established guidelines are met
  • Communicates with insurance agencies to obtain needed care
  • Coordinates case management services to ensure the multidisciplinary team meets the needs of the member
  • Performs discharge planning duties including but not limited to obtaining medical equipment as needed upon discharge
  • Represents the department/division at internal and external meetings
  • Preserves patient and staff confidentiality to ensure strict adherence to related privacy policies and regulations
  • Keeps abreast of health payer benefits, regulations and requirements, disease processes and treatment modalities, community standards of patient care, appropriate quality monitoring techniques, professional medical standards of practice, government, payers, and accrediting organizations' requirements
  • Acts as a preceptor and orients new staff
  • Supervises subordinates and performs other related duties as assigned


When assigned to the Mental Health and Detention Divisions:
  • Coordinates a team approach to review and case management
  • Performs concurrent and retrospective inpatient or outpatient care review
  • Reviews requests for services, which require prior authorization to determine if established guidelines are met
  • Communicates with insurance agencies to obtain needed care
  • Coordinates case management services to ensure the multidisciplinary team meets the needs of the member
  • Monitors for adequate, consistent and appropriate medical record documentation as it relates to medical necessity, utilization or resources, quality of care and discharge planning and teaches providers appropriate and required medical documentation
  • Communicates with physicians and other healthcare professionals in relation to Utilization Review, Quality Assurance and Improvement and Case Management issues (includes gathering information, passing on information, coordinating and arranging for care, teaching providers)
  • Is a member of the Utilization Management Committee and provides utilization statistics, trends and reports; informs committee members about related issues and problems; initiates action to improve utilization
  • Quality assurance/improvement tasks include researching, studying, monitoring and reporting quality care issues and outcomes, communicating standards of care, initiating and coordinating related activities to improve care
  • Case management tasks include performing care needs assessments that cover the continuum of care early in the treatment course to facilitate coordination of activities for a smooth and safe transition from one level of care to another and care coordination activities to assist the patient in navigating through the Health Care Delivery System
  • Coordinates the transfer of patients from CCRMC or County Detention facilities to other medical facilities
  • Care coordination including oversight of continuity of care within County Mental Health Programs and/or detention facilities and between County and community based organizations
  • Participates in internal and external audits for reimbursement, quality of care and utilization of resources
  • Represents the department/division at internal and external meetings
  • Preserves patient and staff confidentiality to ensure strict adherence to related privacy policies and regulations
  • Keeps abreast of health payer benefits, regulations and requirements, disease processes and treatment modalities, community standards of patient care, appropriate quality monitoring techniques, professional medical standards of practice, government, payers, and accrediting organizations' requirements
  • Acts as a preceptor and orients new staff
  • Performs other related duties as assigned

Minimum Qualifications
License Required: Candidates must possess and maintain throughout the duration of employment a current, valid and unrestricted license as a Registered Nurse in the State of California.

Experience:
Contra Costa County Regional Medical Center and Detention Facility Assignments: Two (2) years of full-time (or the equivalent of full-time) experience as a Registered Nurse in an acute care hospital

Contra Costa Health Plan Assignments: Two (2) years of full-time (or the equivalent of full-time) experience as a Registered Nurse in a hospital, outpatient, health plan or clinic setting, one year of which must have included experience as a Utilization Review Nurse, Discharge Planner, or Case Management Nurse in a managed care setting (e.g. Preferred Provider Organization, Managed Care Organization, or Health Maintenance Organization).

Mental Health Division Assignments: Two (2) years full-time (or the equivalent of full-time) experience, as a registered nurse in a 24-hour psychiatric care facility or outpatient mental health system, or one year of full-time or its equivalent experience as a Utilization Review Nurse, Discharge Planner, or Case Management Nurse in a managed care setting (e.g. Preferred Provider Organization, Managed Care Organization, or Health Maintenance Organization), or in an acute or outpatient care setting.

Substitution: Possession of a bachelor's degree in nursing may be substituted for six (6) months of the required experience except in the Public Health assignment.
Selection Process
1. Application Filing: All applicants must apply on-line at www.cccounty.us/hr and submit the information as indicated on the job announcement by the final filing date. A completed Supplemental Questionnaire is required at the time of applying.

2. Application Evaluation: Depending on the number of applications received, an Application Evaluation Board may be convened to evaluate and select the best-qualified candidates for invitation to the next phase of the examination.

3. Training and Experience Evaluation: Consists of an evaluation of each candidate's relevant education, training and/or experience as presented on the application and supplemental questionnaire. (Weighted 100%)

4. Candidates must receive a score of at least 70, which may be an adjusted score, in order to be ranked on the employment list.

The Human Resources Department may change the examination steps noted above in accordance with the Personnel Management Regulations and accepted selection practices. As part of the application process, an applicant may be required to complete a Conviction History form. The Conviction History form should only be submitted when requested.

CONVICTION HISTORY
After you receive a conditional job offer, you will be fingerprinted, and your fingerprints will be sent to the California Department of Justice (DOJ) and the Federal Bureau of Investigation (FBI). The resulting report of your conviction history (if any) will be used to determine whether the nature of your conviction conflicts with the specific duties and responsibilities of the job for which you have received a conditional job offer. If a conflict exists, you will be asked to present any evidence of rehabilitation that may mitigate the conflict, except when federal or state regulations bar employment in specific circumstances. Having a conviction history does not automatically preclude you from a job with Contra Costa County. If you accept a conditional job offer, the Human Resources department will contact you to schedule a fingerprinting appointment.

DISASTER SERVICE WORKER
All Contra Costa County employees are designated Disaster Service Workers through state and local law. Employment with the County requires the affirmation of a loyalty oath to this effect. Employees are required to complete all Disaster Service Worker-related training as assigned, and to return to work as ordered in the event of an emergency.

EQUAL EMPLOYMENT OPPORTUNITY
It is the policy of Contra Costa County to consider all applicants for employment without regard to race, color, religion, sex, national origin, ethnicity, age, disability, sexual orientation, gender, gender identify, gender expression, marital status, ancestry, medical condition, genetic information, military or veteran status, or other protected category under the law.