osceola Work Opportunities ∙ Page 5

Provides assistance and back-up for QI/UM/RM Analyst by verifying admission screening is appropriate for effective utilization of hospital days and services. Reviews patient records and abstracts information needed for insurance calls and utilization review documentation for outpatients and inpatients. Duties include, but are not limited to: Specialty Clinic preparation, medical necessity, and authorizations. Performs authorizations and reviews on all outpatient surgery, hospital based specialty clinics and therapy orders. Performs credentialing peer review.

Key Accountability

• Outpatient Utilization Review Services

Key Accountability

• Medical Staff Meeting Preparation (audits, peer review, etc)

Key Accountability

• Back up for Inpatient Utilization Review Services

Basic Clarke County Hospital (CCH) Performance Criteria     

• Demonstrates Clarke County Hospital Standards of Behaviors as well as adheres to hospital policies and procedures and safety guidelines.
• Demonstrates ability to meet business needs of department with regular, reliable attendance.
• Employee maintains current licenses and/or certifications required for the position.
• Practices and reflects knowledge of HIPAA, DIA, DNV, OSHA and other federal/state regulatory agencies guiding healthcare.
• Completes all annual education and competency requirements within the calendar year.
• Is knowledgeable of hospital and department compliance requirements for federally funded healthcare programs (e.g. Medicare and Medicaid) regarding fraud, waste and abuse. Brings any questions or concerns regarding compliance to the immediate attention of hospital administrative staff.  Takes appropriate action on concerns reported by department staff related to compliance.

Qualifications

Education: High School Diploma. Preferred: College Degree

Experience: Two years of experience in clinical setting. Medical background sufficient enough to review patient records and abstract information needed to perform job duties. Preferred: Utilization Review Experience.

License(s)/Certification(s): Valid driver's license when driving any vehicle for work-related reasons.

Knowledge/Skills/Abilities: Good communication skills to work with physicians, outside agencies, and hospital personnel. Basic computer and typing skills, ability.

Shifts/Schedules: Normal Business hours/ Remote (40 hours per week)