Facility Care Manager/Utilization Management Nurse

            **** THIS POSITION WILL BE IN Richland WA, Boise ID or Portland OR***

GENERAL SUMMARY OF DUTIES:  Review appropriate utilization of medical services, quality of care, risk management and provides intervention for care management. Assist the working committees in utilization and care management.

1. Review concurrent and retrospective inpatient and/or subacute admissions for utilization based on Milliman Care Guidelines criteria, quality assurance, risk management, and discharge planning needs.
2. Develop and maintain a good working relationship with the healthcare team, to include correctional institution personnel.
3. Seek appropriate medical and/or staff intervention in a timely manner to assure problem prevention and resolution.
4. Assess patient’s medical and psychosocial needs to develop, communicate and implement a comprehensive plan of care in collaboration with the healthcare team.
5. Document pre-authorizations, concurrent and retrospective reviews, care management, discharge plan in appropriate care management system to track variance and quality indicators.

OTHERS DUTIES/RESPONSIBILITIES:

1. Participate in Medical Director conference calls.
2. Participate in weekend on-call schedule rotation as needed.

EDUCATION:

1. Graduate of accredited school of nursing with BSN (may be waived for individual who has an RN, SW degree or diploma associate degree in nursing and demonstrates experience in quality assurance UR or discharge planning).

EXPERIENCE: 

1. Three (3) to five (5) years clinical nursing experience.

REQUIREMENTS: 

1. Must have a valid driver’s license and reliable transportation.
2. 50% travel weekly to hospital facilities and correctional institutions including the Portland area, Northern Oregon, Richland Washington and Eastern Oregon i.e. Ontario, OR.

KNOWLEDGE: 

1.    Knowledge of care management.

2.    Knowledge of community resources/agencies.

3.    Knowledge of NCQA, QA, Medicare/Medicaid guidelines.

4.    Knowledge of program and workflow development, process improvement and implementation procedures.

 SKILLS: 

1.    Skilled in conflict management to assure problem prevention and resolution. 

2.    Skilled in developing and maintaining positive relationships and communicating effectively with internal staff and external customers. 

3.    Skilled in organization, coordination and facilitation of meetings and/or events.

ABILITIES: 

1. Able to perform basic to intermediate level of competence with various computer software applications including MS Outlook, Word, Excel, Access and Power Point. 
2. Able to effectively communicate with internal staff and external customers. 
3. Able to solve resource issues in a creative, positive manner to improve clinical outcomes of patients. 
4. Able to work with the outpatient care management team members to most effectively manage members.   
5. Able to participate in program development in order to identify appropriate goals of program.