Sr Clinical Admin Nurse RN

About the Role

This position serves as the in-state designee for the organization's Home Health license while also providing day-to-day clinical coordination and agency management support. The individual will work closely with the Director of Nursing and Agency Management Team to oversee contracted home health agencies, coordinate patient care activities, monitor treatment plans, and ensure regulatory compliance.

Key Responsibilities

• Educate nursing agencies regarding guidelines for providing quality and efficient care, expected best practices per Optum standards
• Screen or respond to nursing agency requests (e.g., clinical concerns, training requests, questions regarding rules/guidelines, visit duration expectations)
• Provide feedback/information to internal or external customers (e.g., trends, feedback on prevention of errors, communication of findings)
• Educate others around new or existing regulatory requirements
• Find answers to basic questions and determine what other information could provide a more complete understanding of the situation
• Leverage technology including on-line resources (e.g., Internet sites, internal websites) or other internal systems (e.g., claims/invoices processing system, care management document systems) to research information, understand/define information provided, and document information
• Identify information and records that are needed based on the situation and request or find information
• Obtain information from appropriate stakeholders (members, clinicians, internal staff)
• Review detailed clinical information, analyze and interpret clinical documentation, determine relevance, and make clinically sound conclusions (e.g., care management, regulatory, clinical risk management)
• Present findings of clinical or other reviews (e.g., Medicare payment accuracy, training needs) to relevant parties and/or send summary information to others for review
• Review work and/or respond to findings and identify/correct errors to ensure accurate information is presented or documented (e.g., quality audits/reviews)
• Develop action plans based on clinical review/findings/audits
• Demonstrate knowledge of healthcare insurance industry products and regulations (e.g., HMO, Medicare, Medicaid)
• Demonstrate knowledge of applicable regulatory requirements (e.g., OSHA, HIPAA, CMS, vendor compliance, DOI, DMHC)
• Demonstrate knowledge of nursing functions within the healthcare insurance industry (e.g., utilization review procedures, case management, appeals and grievance procedures)
• Demonstrate knowledge of applicable area of specialization (e.g., training, appeals, interface/liaison, operations analysis, clinical writing)
• Demonstrate knowledge of managed care models (e.g., IPA, group practice)
• Identify relevant internal policies and regulatory guidelines
• Ensure compliance with clinical guidelines
• Establish/follow compliance procedures and enforce regulations and guidelines
• Complete applicable documentation (e.g., draft letters of denial/approval, member/provider contacts) following relevant internal and external regulations and guidelines
• Follow departmental processes (e.g., workflows, job aids)
• Write and/or enforce policies to minimize risk and meet external regulatory requirements
• Demonstrate understanding of business implications of clinical decisions (e.g., financial ramifications)
• Ask critical questions to ensure member/customer centric approach to work
• Identify and consider appropriate options to mitigate issues related to quality, safety or affordability when they are identified, and escalates to ensure optimal outcomes, as needed
• Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
• Identify and implement innovative approaches to the practice of nursing, in order to achieve or enhance quality outcomes and financial performance
• Use appropriate business metrics (e.g., member/FTE, length of stay, readmission rates, STAR ratings, member engagement rates) and applicable processes/tools (e.g., cost benefit analysis, return on investment, performance, staffing calculator) to optimize decisions and clinical outcomes
• Prioritize work based on business algorithms and established work processes, or in their absence, identify business priorities and build consensus to triage and deliver work (e.g., assessments, case/claim loads, previous hospitalizations, acuity, morbidity rates, quality of care follow up)
• Understand and operate effectively/efficiently within legal/regulatory requirements (e.g., HIPAA, ARRA, SOX, CHAP, accreditation, state)

Required Qualifications

• Current unrestricted RN licensure in Utah
• Willing to work on site at our office in Draper, UT. Potential to go hybrid or remote down the road

Schedule

Monday-Friday, 8am-5pm, on-site at our office in Draper UT. Possibility to go hybrid or remote in future.

Pay & Benefits

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. The salary for this role will range from $60,200 - $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.

In addition to your salary, we offer benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives.