Chart Utilization Review Jobs in Oklahoma (NOW HIRING)

We are currently looking for a Full Time Inpatient Case Manager to join our Inpatient Case Management and Social Worker Team team located at the Chickasaw Nation Medical Center working 8:00AM-5:00PM - Mo Tu We Th Fr.
Summary:
Provides comprehensive nursing care and care coordination, including patient education, clinical support, case management, and utilization review activities to support appropriate resource use and patient care. Collaborates with providers and interdisciplinary teams to optimize workflows, improve outcomes, and support organizational performance initiatives in compliance with regulatory standards.
Responsibilities:
* Oversees daily management of care coordination for Native American patients by assessing, planning, and organizing health care services within a framework of established guideline/protocols, health status of patients, and available funds/resources
* Generates and faxes/copies patient protected health information necessary for continuum of care to outside healthcare facilities and/or providers, ensuring that all records needed for this process are accurate and valid, while maintaining patient confidentiality, security and integrity of data and information in accordance with HIPAA and the Minimum Necessary Rule, and noting within the patient's EHR each disclosure according to CNDH documentation policy
* Develops and implements care within the CNDH to ensure continuity of care, decrease fragmentation of services, and enhance health promotion disease prevention activities
* Identifies and screens cases, determines the availability of community resources, evaluates that status of the patient's mental and physical capabilities and provides coordination
* Uses computer system and medical record to conduct admission and continued stay reviews
* Ensures documentation of appropriate level of care
* Documents in the medical record for the purpose of treatment and referral options
* Shares clinical information with providers and other health care professionals
* Monitors patients assigned to 23-hour observation status and when necessary, communicates with hospital staff and/or attending physician
* Monitors admission, screens referrals, performs interviews, and interventions
* Serves as a resource to identify all possible patient resources and potential payer sources
* Works with the family to identify possible alternate funding such as Medicare, Medicaid, veteran's health benefits, disability, vocational rehabilitation, or tribal programs/services
* Serves as a resource for nurses, providers, and the patient/family during the care coordination process and discharge planning
* Facilitates referrals to outside agencies such as home health agencies, need for durable medical equipment (DME), hospice, nursing homes, long term care, etc
* Assists social work services with discharge planning and clinical interpretations as needed
* Establishes a working relationship with other IHS providers and hospitals; external providers and hospitals; tribal health programs providers and hospitals; home health agencies; community outreach programs; and customers of the Chickasaw Nation Department of Health
* Tracks potentially avoidable days for reporting to the Discharge Planning Committee
* Consults with the physician advisor when indicated by review results
* Works closely with hospitalist and supporting staff to make appropriate referrals for continued follow-up and care following discharge from the acute care setting
* Ensures that case management activities are ethical and of value to the patient, their family, and the providers of care both within and outside the health system
* Maintains case management review forms on all new admissions and concurrent reviews
* Participates in multidisciplinary discharge planning meetings, reporting on potential avoidable days, and emphasizing the team approach in care and subsequent discharge of patients
* Develops and implements methodology of securing, retrieving, gathering and analyzing data relative to internal and external health care provision, as it related to utilization management, quality improvement, and case management
* Conducts chart audits in an effort to demonstrate health system performance and identify areas of concerns
* Performs record reviews for the business office, Admissions/Registration, and HIM
* Assists in the system-wide preparation for pre- and post-Joint Commission survey activities
* Interacts and maintain professional working relationship with all other CNDH departments and employees, medical staff, and all other Chickasaw Nation departments
* Conducts concurrent utilization review activity
* Reviews medical record to ensure that patients have a condition that requires treatment (indication for hospitalization element) and that the treatment can be safely provided only in the appropriate inpatient setting (treatment element)
* Serves as a liaison to coordinate retrieval of patient information required by 3rd party payer case management activities (Medicare, Medicaid and private insurance)
* Provides case review information as needed for approval and documentation for billing
* Reviews and analyzes medical records to assess whether planned surgical procedures are medically necessary and admission to the hospital is justified
* Provides activity data review for reporting on a quarterly basis
* Assists in responding to the state quality improvement organization (QIO) queries and studies
* Cross-trains and provides support/back-up for other professional positions within the Inpatient Case Management department
* Assists in identifying activities and data collection for performance improvement
* Participates in revenue cycle management and demonstrates awareness of the need to control expenses
* Acts as a resource/consultant to hospital and medical staff in the care of case management
* Assists in orientation and education of department personnel
* Provides feedback and focused educational programs on the results of admission screening reviews to affected staff and physicians
* Provides first class customer service to both internal and external customers and responds to inquiries, compliments, and/or complaints with professionalism, courtesy, and efficiency
* Completes all training and development requirements and participates in continuing education opportunities
* Works in a collaborative and supportive manner to support the productivity and safety of the work area, team members and customers of all types
- Maintains a clean, organized work area and ensures a safe environment
- Maintains and promotes professionalism
- Punctual and consistent in meeting start time, work schedule, attendance and other assigned work time metrics
- Adheres to Chickasaw Nation dress code standards
* Maintains knowledge of and follows all rules, regulations, policies and guidelines for assigned area
* Performs all other duties as assigned
Competencies:
Essential:
* Ability to review and analyze claims, denials, and rejections
* Demonstrated ability and skill in auditing and interpreting medical records
* Able to follow instructions, both written and oral
* Able to adhere to all scheduling and attendance requirements
* Ability to maintain a high level of confidentiality in all matters
* Must be able to exert analytical and critical thinking skill
* Honesty, truthfulness, reliability, accountability
* Prioritizes, meets deadlines and works independently in a high-pressure environment and uses appropriate judgement in upward communication regarding assignments
* Able to read, understand, apply, and retain knowledge of Chickasaw Nation, departmental, divisional and all other rules, regulations, policies, procedures and guidelines
* Knowledge of federal, state and payer-specific regulations and policies pertaining to documentation, coding, and billing
* Learn and apply Health Insurance Portability and Accountability Act (HIPAA), Privacy Act, Federal Advisory Committee Act (FACA), Federal Tort Claims Act (FTCA), Freedom of Information Act, Compliance Standards, Joint Commission Accreditation, and other various regulations
* Knowledge of third party payor guidelines
* Demonstrates effective oral and written communication
* Knowledge and understanding of Center for Medicare and Medicaid Systems (CMS) billing and coding requirement and compliance expectations
* Strong leadership, communication, and interpersonal skills, with the ability to lead and motivate team members
* Able to verbally communicate in a professional and positive manner with other team members, departments, guests and management
* Maintains clear and complete employee health records
Skills:
Essential:
* Basic Computer skills
* Must be familiar with the Microsoft Office Suite of products
Experience:
Nonessential:
* 2 years directly related experience
Education:
Essential:
* Graduate from an accredited school of nursing required
Nonessential:
* Bachelor's of Nursing
Credentials:
Essential:
* Pass general background check
* Basic Life Support (BLS)
* Registered Nurse
Nonessential:
* Certified Professional in Healthcare Quality
* Certified Case Manager (CCM)
Essential:
* Must maintain BLS certification or obtain within 1 month of hire, if not current
Working Conditions:
Essential:
* Works in a hospital or clinic environment
* Stressful environment due to any or a combination of deadlines, pressures, multiple tasks, lines of communication, risks, speed of operations, etc.
* Potential exposure to contagious diseases
* May be required to assist individuals who are hostile, agitated or under the influence
* May be required to assist individuals with unmanaged emotions
* Frequently bend, kneel, stoop, push, reach
* Standing up to 100% of shift
* Walking up to 100% of shift
* Sometimes lift and or carry over 50 lbs
* May work evenings, weekends or holidays
* Pass pre-employment drug test
Training
*It is the responsibility of each employee to attend required training for their position or profession as determined by their line of support (LOS) or the leadership of the Chickasaw Nation. It is the responsibility of those who supervise, manage or otherwise lead employees or teams to ensure each employee has access to and receives all required training.
Mission, Vision & Core Values
Mission:
*To enhance the overall quality of life of the Chickasaw people.
Vision:
*To be a nation of successful and united people with a strong cultural identity.
Core Values:
*The Chickasaw People
*Cultural Identity
*Servant Leadership
*Selflessness
*Can Do Attitude
*Perseverance
*Stewardship
*Trust and Respect
*Loyalty
*Honesty and Integrity
*Teamwork