Utilization Review Nurse - Utilization Management - Remote Work Schedule

The Alaska Native Tribal Health Consortium is a non-profit Tribal health organization designed to meet the unique health needs of Alaska Native and American Indian people living in Alaska. In partnership with the more than 171,000 Alaska Native and American Indian people that we serve and the Tribal health organizations of the Alaska Tribal Health System, ANTHC provides world-class health services, which include comprehensive medical services at the Alaska Native Medical Center, wellness programs, disease research and prevention, rural provider training and rural water and sanitation systems construction.

ANTHC is the largest, most comprehensive Tribal health organization in the United States, and Alaska’s second-largest health employer with more than 3,100 employees offering an array of health services to people around the nation’s largest state.

Our vision: Alaska Native people are the healthiest people in the world.

ANTHC offers a competitive and comprehensive Benefits Package for all Benefit Eligible Employees, which includes:

• Medical Insurance provided through the Federal Employee Health Benefits Program as a Tribal Employee, with over 20 plans and tiers.

• Cost-Share Dental and Vision Insurances

• Discounted Pet Insurance

• Retirement Contributions with Pre-Tax or Roth options into a 403(b).

• 401(a) ANTHC Retirement Plan: After one year of employment, ANTHC will begin making matching contributions of up to 5% of your eligible pay, based on your own contributions. In addition, you may be eligible for an annual discretionary contribution of up to 3% from the employer.

• Paid Time Off starts immediately, earning up to 6 hours per pay period, with paid time off accruals increasing based on years of service.

• Eleven Paid Holidays

• Paid Parental Leave or miscarriage/stillbirth eligibility after six months of employment

• Basic Short/Long Term Disability premiums, Accidental Death and Dismemberment (AD&D) Insurance, and Basic Life Insurance are covered 100% by ANTHC, with additional options for Short-Term Disability Buy-Up Coverage and Voluntary Life for yourself and your family members.

• Flexible Spending Accounts for Healthcare and Dependent Care.

• Ancillary Cash Benefits for accident, hospital indemnity, and critical illness.

• On-Site Child Care Facility with expert-designed classrooms for early child development and preschool.

• Employee Assistance Program with support for grief, financial counseling, mental/emotional health, and discounted legal advice.

• Tuition Discounts for you and your eligible dependents at Alaska Pacific University.

• On-Site Training Courses and Professional Development Opportunities.

• License and certification reimbursements and occupational insurance for medical staff.

• Gym Access to Alaska Pacific University includes a salt water pool, rock climbing, workout gym, and steep discounts for outdoor equipment rentals.

• Emergency Travel Assistance

• Education Assistance or Education leave eligibility

• Discount program for travel, gym memberships, amusement parks, and more.

or contact Recruitment directly at [email protected].

Alaska Native Tribal Health Consortium has a hiring preference for qualified Alaska Native and American Indian applicants pursuant to P.L. 93-638 Indian Self Determination Act.

Summary:

Under general direction, provides professional assessment, planning, coordination, implementation, and reporting of complex clinical data, and supports the operations of the ANMC hospital services.

Responsibilities:

Performs utilization review in accordance with all state mandated regulations. Maintains compliancy with regulation changes affecting utilization management. Reviews patients’ records and evaluates patient progress.

Performs continuing review on medical records and evaluates need for ongoing hospitalization. Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct reviews, validate physician’s orders, and report progress and unusual occurrences on patients. Ensures appropriate and cost-effective healthcare services to patients.

Documents review information in computer. Communicates results to claims adjusters. Enters billing information for services. Prepares information for notification letters for providers. Receives and processes requests for appeal of denials. Responds to complaints per Utilization Review (UR) guidelines. Maintains utilization review and appeal logs, as needed, by jurisdiction.

Analyzes patient records and participates in interdisciplinary collaboration with professional staff. Facilitates educational programs and advises physicians and other departments of regulations affecting utilization management. Consults with members of the healthcare team regarding the level of nursing care and collaborates with other departments in evaluation of projects affecting discharge plans.

Reviews and updates cases daily. Able to manage caseload with minimal supervision. Creates and maintains assignment spreadsheets.

Supports clinical improvement activities of ANMC Clinic Core Business Groups by providing quality review records and reports all information within scope of authority as directed. Participates in quality improvement activities as directed.

Performs administrative duties. Receives, logs, and files a variety of reports, client charts, client interactions and other documents.

Other information:

KNOWLEDGE and SKILLS

• Knowledge of modern nursing principles, techniques, and procedures for the care of patients.
• Knowledge of medical terminology, anatomy, physiology and concepts of disease.
• Knowledge of Alaskan Tribal Health System, ANTHC, and Alaska Native culture(s) and politics.
• Knowledge of InterQual criteria.
• Knowledge of PCS, ICD-10-CM, and HCPCS nomenclature, and coding rules and guidelines.
• Knowledge of Centers for Medicare and Medicaid Services (CMS), Joint Commission (JCR), and Health Care Financing Administration (HCFA) standards affecting medical records and the impact on reimbursement and accreditation.
• Skill in reviewing medical records for extrapolating medical necessity.
• Skill in organization and time management.
• Skill in making decisions independently.
• Skill in operating a personal computer utilizing a variety of software applications.
Skill in strong written and oral communication

MINIMUM EDUCATION QUALIFICATION

Associate Degree in Nursing.

MINIMUM EXPERIENCE QUALIFICATION

Non-supervisory – Three (3) years of clinical care or nursing experience AND two (2) years Utilization Review or chart extraction/quality review experience. An equivalent combination of relevant education and/or training may substitute for experience.

MINIMUM CERTIFICATION QUALIFICATION

· Current registered nurse license

· Current Basic Life Support (BLS) card

PREFERRED EDUCATION QUALIFICATION

· Bachelor’s degree in Nursing is preferred.

PREFERRED EXPERIENCE QUALIFICATION

· Experience in InterQual or MCG (Milliman) is preferred.