Location: Fairbanks, Alaska
The position is primarily accountable for performing initial clinical appropriateness reviews of requests for services that require prior authorization, initial, concurrent and/or retrospective review The review process is performed in accordance with established patient (health plan) protocols/guidelines, benefits, and clinical appropriateness criteria (clinical screening criteria). This position works closely with the Care Coordinators, Discharge Planners, Social Workers, Registration and Providers to evaluate, monitor, and assure the appropriateness and medical necessity of selected care for patients as it relates to quality, continuity, and cost-effectiveness. This position works with clinical and non-clinical staff as part of the referral and/or authorization process. This position is responsible for managing utilization and, if necessary, discussing the utilization of service and standards of patient management.
About Fairbanks Memorial Hospital
Fairbanks Memorial Hospital is a non-profit facility owned by the Greater Fairbanks Community Hospital Foundation. A Joint Commission-accredited facility with 152 licensed beds, Fairbanks Memorial Hospital is the primary referral center for residents of Alaska's interior with a strong patient-to-nurse ratio and Shared Leadership Infrastructure. In addition to our exceptional clinical environment, our location offers incomparable lifestyle rewards away from work. In Fairbanks, small-town living, spectacular natural beauty and endless recreation combine to create a one-of-a-kind place to live, work and play.
**Must reside in the state of Alaska and have AK RN licensure**
ResponsibilitiesThe position is primarily accountable for performing initial clinical appropriateness reviews of requests for services that require prior authorization or retrospective review Facilitates cost-effective and quality patient care by effective communication with leadership, providers, and patient care team. Ensures authorized services are performed in the most cost-effective appropriate setting (Inpatient or Outpatient). Evaluates the medical necessity and appropriateness of care, optimizing patient outcomes. Assesses patient admissions and continued stay utilizing standard criteria. Establishes and promotes a collaborative relationship with physicians, payers, and other members of the health care team. Collects and communicates pertinent, timely information to payers and others to fulfill utilization and regulatory requirements. Educates internal members of the health care team on case management and managed care concepts. Facilitates integration of concepts into daily practice. May supervise other staff.
Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers of Foundation Health with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day.
NOTE: The essential functions are intended to describe the general content of and requirements of this position and are not intended to be an exhaustive statement of duties. Specific tasks or responsibilities will be documented as outlined by the incumbent's immediate manager.
Must possess knowledge of case management or utilization review as normally obtained through the completion of a bachelor's degree in case management or health care.
Requires current Registered Nurse (R.N.) license in state worked. For assignments in an acute care setting,
Basic Life Support (BLS) certification is also required.
Requires a proficiency level typically achieved with 5 years clinical experience. Must have a working knowledge of care management, acute care and/or home care environments, community resources and resource/utilization management. Must demonstrate critical thinking skills, problem-solving abilities, effective communication skills, and time management skills. Must demonstrate ability to work effectively in an interdisciplinary team format. For assignments in an acute care setting, must be able to work flexible hours and take rotating call after hours. Foundation Registry and Travel positions require a minimum of one year experience in an acute care hospital and/or home care setting. Experience must include working in an acute care and/or home care setting within the past 12 months as a Case Manager in the specialty area.
CCM (Certified Case Manager) preferred
Additional related education and/or experience preferred.